So far in the course you’ve been learning about depression, what it’s key symptoms are and how it is different from the normal ups and downs in our mood that we all experience over time.
We explored the impact of low mood on behaviour and the consequences of behaviour in maintaining low mood. We learnt that depression is maintained by avoidance, procrastination and the absence of rewarding activities that connect us with people and things that are important to us. We briefly introduced behavioural activation as an intervention that can help depression by increasing rewarding activities and by reducing avoidance and procrastination.
In section 3 we’ll look in more detail at how behavioural activation works and can be applied in practice. We will also look at evidence for its effectiveness across different ages and cultures.
Watch Masuma’s short intro video to section 3.
Unlocking behavioural activation
Explore key components of behavioural activation and how they can be put into practice.
Core elements of behavioral activationBehavioural activation is typically delivered in regular sessions with a trained person who may be a psychologist, a nurse or a doctor, a pastoral member of staff in a school, a social worker or a charity worker. Behavioural activation can be delivered face-to-face, by telephone, or online.
Written materials and workbooks are often used to help guide the person through the step-by-step structure of the intervention; also, to provide further reading and facilitate trying out new techniques and completing new activities between sessions.
Behavioural activation can be described in four core elements.
(1) Functional analysis
(2) Activity scheduling
(3) Goal setting
(4) Relapse prevention
We will look at each one in turn.
Functional analysisDo you remember meeting Deepak in section 1 and learning about the A-B-C model in section 2?
Let’s watch a consultation Deepak has with a mental health worker, Naveed, where they apply a technique called functional analysis.
What is functional analysis?
Functional analysis is a process by which we can apply the A-B-C model to an individual’s circumstances, actions, and feelings. The aim of the functional analysis is to understand the causes and consequences of someone’s behaviour in the context of their life and experiences.
Through a series of questions, a functional analysis finds out:
A. What situations in a person’s life trigger feelings of unhappiness, worry, shame or frustration (Antecedents)
B. What does the person avoid doing, or is doing less, or is doing more than usual to cope and deal with the situation (Behaviours)
C. How the person’s avoidance or activity give them or deprive them of emotional rewards (Consequences).
We have already talked about how depression is the result of missed opportunities to connect with people and things that can act as sources of positive reinforcement by giving us emotional rewards: pleasure, achievement, and connection with what is important to us.
Completing a functional analysis is a stepping stone for the next stage of behavioural activation, which is activity scheduling. The functional analysis helps us identify:
- Avoidance, procrastination, and rumination, which we aim to override through activity scheduling.
- Positively reinforced behaviours (enjoyable, purposeful, and rewarding activities) which we aim to increase through activity scheduling.
Behavioural activation is typically delivered in regular sessions with a trained person who may be a psychologist, a nurse or a doctor, a pastoral member of staff in a school, a social worker or a charity worker. Behavioural activation can be delivered face-to-face, by telephone, or online.
Written materials and workbooks are often used to help guide the person through the step-by-step structure of the intervention; also, to provide further reading and facilitate trying out new techniques and completing new activities between sessions.
Behavioural activation can be described in four core elements.
(1) Functional analysis
(2) Activity scheduling
(3) Goal setting
(4) Relapse prevention
We will look at each one in turn.
Do you remember meeting Deepak in section 1 and learning about the A-B-C model in section 2?
Let’s watch a consultation Deepak has with a mental health worker, Naveed, where they apply a technique called functional analysis.
What is functional analysis?
Functional analysis is a process by which we can apply the A-B-C model to an individual’s circumstances, actions, and feelings. The aim of the functional analysis is to understand the causes and consequences of someone’s behaviour in the context of their life and experiences.
Through a series of questions, a functional analysis finds out:
A. What situations in a person’s life trigger feelings of unhappiness, worry, shame or frustration (Antecedents)
B. What does the person avoid doing, or is doing less, or is doing more than usual to cope and deal with the situation (Behaviours)
C. How the person’s avoidance or activity give them or deprive them of emotional rewards (Consequences).
We have already talked about how depression is the result of missed opportunities to connect with people and things that can act as sources of positive reinforcement by giving us emotional rewards: pleasure, achievement, and connection with what is important to us.
Completing a functional analysis is a stepping stone for the next stage of behavioural activation, which is activity scheduling. The functional analysis helps us identify:
- Avoidance, procrastination, and rumination, which we aim to override through activity scheduling.
- Positively reinforced behaviours (enjoyable, purposeful, and rewarding activities) which we aim to increase through activity scheduling.
Think of a few situations that make you unhappy, frustrated, or anxious. This could relate to your health, your work or your home life.
- What sort of things do you avoid doing, or things that you do excessively, when you feel unhappy, frustrated, or anxious about a situation?
- How does this help you or the situation?
Now think of times when you felt at your best: happy, productive, energised, or relaxed. This could be a particularly good time in your life from the past, or certain times on a good week or on a good day at present.
- What sort of things you do when you feel happy, productive, energised or relaxed?
- What gets in the way of doing more of these things?
Activity schedulingActivity scheduling is a weekly plan of enjoyable, purposeful and rewarding activities that can lift a person’s mood, re-stimulate their interest and enjoyment in life, energise them and reconnect them with people and things that are important to them.
The weekly calendar
The weekly plan takes the form of a simple calendar, in which we schedule each activity on a specific day and at a specific time.
As we complete our scheduled activities, we assign a score to each one: these scores represent how much pleasure and a sense of achievement each activity gives us and how much we feel it connects us with important areas of life.
We rate each activity on a scale of 0-10: 0 = no enjoyment/achievement/connection, 10 = great enjoyment/achievement/connection.
Why do you think a written calendar of scheduled activities is more helpful than a long to-do list or just rely on remembering what we want to do?
A calendar is more helpful than making a list of things to do over a week, or just remembering what we want to do, even if we only choose to do a couple of things during that week.
Firstly, using a calendar helps us to fit chosen activities into our lives because we schedule them for days and times that work best for us, for example, when family members are around to help or to fit around work or other commitments. This means that we are more likely to complete the activities successfully. A calendar also looks more manageable and less
overwhelming than a long list of things to do, because the activities are visually spread out.
Secondly, when we are depressed, we tend to focus on negative things and underestimate our achievements. A written record of how much we do, and what we do, is a more accurate representation of our activity. In behavioural activation we record not only what we scheduled to do, but also what we spontaneously or routinely do each day. Often, people are surprised by how much they do during a week when they see their completed calendar, as they previously thought that they did very little.
Finally, a calendar offers structure that is important to stop procrastination (putting activities off) and rumination (thinking about what to do but not doing it). Scheduling the activity on a certain day and at a certain time reinforces the principle that our actions in behavioural activation are driven by a purpose and not by our mood.
What types of activities go on a weekly calendar?
The starting point of activity scheduling is to find out what things are important for each person: what they value about themselves and in other people, who matters to them, and what things take priority in their lives.
This is like a jigsaw puzzle, where different pieces – such as family, relationships, work, school, physical health, mental health, self-image, knowledge, adventure, creativity, security, autonomy, charity – make up our life.
Activities that connect with what is important to us are more meaningful than activities that we do out of habit or because other people suggested them. Activity scheduling covers different important areas of someone’s life.
Within and across different areas of life, activities fulfil three different purposes, depending on whether they are things that:
- We want to do; these are day-to-day pleasures that give enjoyment.
- We have to do; these are routine tasks that are necessary in life.
- We plan to do; these are steps towards achieving a bigger or future goal.
Activity scheduling includes a mix of pleasures, routines, and plans across different important areas of life.
Some activities may take more effort than others; it is good to schedule a mixture of easy and more challenging activities. Easy activities give us a boost of motivation and momentum, whereas more challenging – but still manageable – activities lead to a feeling of achievement.
The 4Rs: Replace, Reinstate, Reduce, Restructure
Here are some ways to maximise the effectiveness of activity scheduling:
Activity scheduling is a weekly plan of enjoyable, purposeful and rewarding activities that can lift a person’s mood, re-stimulate their interest and enjoyment in life, energise them and reconnect them with people and things that are important to them.
The weekly calendar
The weekly plan takes the form of a simple calendar, in which we schedule each activity on a specific day and at a specific time.
As we complete our scheduled activities, we assign a score to each one: these scores represent how much pleasure and a sense of achievement each activity gives us and how much we feel it connects us with important areas of life.
We rate each activity on a scale of 0-10: 0 = no enjoyment/achievement/connection, 10 = great enjoyment/achievement/connection.
Why do you think a written calendar of scheduled activities is more helpful than a long to-do list or just rely on remembering what we want to do?
A calendar is more helpful than making a list of things to do over a week, or just remembering what we want to do, even if we only choose to do a couple of things during that week.
Firstly, using a calendar helps us to fit chosen activities into our lives because we schedule them for days and times that work best for us, for example, when family members are around to help or to fit around work or other commitments. This means that we are more likely to complete the activities successfully. A calendar also looks more manageable and less
overwhelming than a long list of things to do, because the activities are visually spread out.
Secondly, when we are depressed, we tend to focus on negative things and underestimate our achievements. A written record of how much we do, and what we do, is a more accurate representation of our activity. In behavioural activation we record not only what we scheduled to do, but also what we spontaneously or routinely do each day. Often, people are surprised by how much they do during a week when they see their completed calendar, as they previously thought that they did very little.
Finally, a calendar offers structure that is important to stop procrastination (putting activities off) and rumination (thinking about what to do but not doing it). Scheduling the activity on a certain day and at a certain time reinforces the principle that our actions in behavioural activation are driven by a purpose and not by our mood.
What types of activities go on a weekly calendar?
The starting point of activity scheduling is to find out what things are important for each person: what they value about themselves and in other people, who matters to them, and what things take priority in their lives.
This is like a jigsaw puzzle, where different pieces – such as family, relationships, work, school, physical health, mental health, self-image, knowledge, adventure, creativity, security, autonomy, charity – make up our life.
Activities that connect with what is important to us are more meaningful than activities that we do out of habit or because other people suggested them. Activity scheduling covers different important areas of someone’s life.
Within and across different areas of life, activities fulfil three different purposes, depending on whether they are things that:
- We want to do; these are day-to-day pleasures that give enjoyment.
- We have to do; these are routine tasks that are necessary in life.
- We plan to do; these are steps towards achieving a bigger or future goal.
Activity scheduling includes a mix of pleasures, routines, and plans across different important areas of life.
Some activities may take more effort than others; it is good to schedule a mixture of easy and more challenging activities. Easy activities give us a boost of motivation and momentum, whereas more challenging – but still manageable – activities lead to a feeling of achievement.
The 4Rs: Replace, Reinstate, Reduce, Restructure
Here are some ways to maximise the effectiveness of activity scheduling:
What do you think about the principle of purpose-driven rather than mood-driven behaviour in behavioural activation?
Download the activity schedule template to monitor what you do during the week.
Download the Activity Schedule template
- Write down each activity as you complete it, rather than at the end of the day or week.
- Write down things even if you consider them “unimportant” or even if you think you were “doing nothing” (e.g. lying in bed).
- Rate each activity on a scale of 0-10:
- 0 = no enjoyment/achievement
- 10 = great enjoyment/achievement
Setting goalsDo you remember meeting Suhana in section one?
Let’s listen to Suhana discussing setting goals with her support worker Leela in the video below.
- Do you think these goals are achievable for Suhana?
- What may get in the way of achieving them?
- Is there anything that you can think of that might help Suhana to stay motivated?
How can we help a person with depression to complete their activities and reach their goals?
- Choose activities that speak to the person’s interests, strengths and skills. These activities are intrinsically motivating.
- Focus on one important activity and allow enough time and opportunities to complete the activity during the week. It is more important to schedule fewer activities that can be completed rather than cram many activities in the weekly calendar.
- Break down the activities into even more steps and repeat them until they are completed with relative ease before moving to more difficult steps.
- Remind someone that in the face of depression most activities will have some degree of difficulty and will take effort to be completed; this is a good thing, because a sense of achievement comes from completing something that takes effort, no matter how small the activity is.
Relapse preventionThe final element of doing behavioural activation is relapse prevention. Relapse prevention is the process of maintaining our gains long-term and reducing the likelihood of becoming depressed again.
Making a relapse prevention plan or a staying well plan
A typical staying well plan is divided up into four sections. This includes looking back to what we have learnt, as well as looking forward to what may happen and how to deal with it.
Maintenance
Things to keep doing that are consistent with behavioural activation: keeping a balance of enjoyable, purposeful, rewarding weekly activities and keep working towards a goal. This begins with a reflective exercise: looking back to how someone felt before beginning behavioural activation, what they have learnt along the way and what has made the difference to how they feel now.
Triggers
Situations and events that are most likely to trigger low mood, anger, worry, hopelessness and other feelings associated with depression. These can be things that we predict may happen at work, in the family, at a certain point in the week, month or year (e.g. holidays). Some things are unpredictable but can still be recognised as triggers: for example illness, relationship breakdown, or loss.
Warning signs
Changes in behaviours or feelings that are warning signs someone is starting to feel depressed. Here are some examples:
Action
Things to start doing, or to do more of, to lift our mood. This begins with retracing our behavioural activation steps and creating a “relapse signature”.
This is a personal pattern that can predict and prevent future setbacks.
Do you remember meeting Suhana in section one?
Let’s listen to Suhana discussing setting goals with her support worker Leela in the video below.
- Do you think these goals are achievable for Suhana?
- What may get in the way of achieving them?
- Is there anything that you can think of that might help Suhana to stay motivated?
How can we help a person with depression to complete their activities and reach their goals?
- Choose activities that speak to the person’s interests, strengths and skills. These activities are intrinsically motivating.
- Focus on one important activity and allow enough time and opportunities to complete the activity during the week. It is more important to schedule fewer activities that can be completed rather than cram many activities in the weekly calendar.
- Break down the activities into even more steps and repeat them until they are completed with relative ease before moving to more difficult steps.
- Remind someone that in the face of depression most activities will have some degree of difficulty and will take effort to be completed; this is a good thing, because a sense of achievement comes from completing something that takes effort, no matter how small the activity is.
The final element of doing behavioural activation is relapse prevention. Relapse prevention is the process of maintaining our gains long-term and reducing the likelihood of becoming depressed again.
Making a relapse prevention plan or a staying well plan
A typical staying well plan is divided up into four sections. This includes looking back to what we have learnt, as well as looking forward to what may happen and how to deal with it.
Maintenance
Things to keep doing that are consistent with behavioural activation: keeping a balance of enjoyable, purposeful, rewarding weekly activities and keep working towards a goal. This begins with a reflective exercise: looking back to how someone felt before beginning behavioural activation, what they have learnt along the way and what has made the difference to how they feel now.
Triggers
Situations and events that are most likely to trigger low mood, anger, worry, hopelessness and other feelings associated with depression. These can be things that we predict may happen at work, in the family, at a certain point in the week, month or year (e.g. holidays). Some things are unpredictable but can still be recognised as triggers: for example illness, relationship breakdown, or loss.
Warning signs
Changes in behaviours or feelings that are warning signs someone is starting to feel depressed. Here are some examples:
Action
Things to start doing, or to do more of, to lift our mood. This begins with retracing our behavioural activation steps and creating a “relapse signature”.
This is a personal pattern that can predict and prevent future setbacks.
Think of times when you feel demoralised, angry, or worried (pick one), even about small things.
You can use your own experiences of normal fluctuations in mood to practice creating a relapse signature.
- The events and situations that can trigger my feeling low/angry/worried are:
- The warning signs that tell me am starting to feel low/angry/worried are:
- When I feel low/angry/worried the best things I can do are:
- When I feel low/angry/worried, the worst things I can do are:
- When I feel low/angry/worried, the people who can be most helpful are:
The evidence base
Looking at the evidence for the value of behavioural activation.
How do we know that behavioural activation can improve depression?Research is important because it provides evidence about whether behavioural activation works to improve depression and for whom it may work better.
Research studies are designed to answer specific questions. Here are two examples:
- Example 1: “Is behavioural activation effective for the treatment of depression in adults compared to usual care (which can include antidepressant medication or other forms of support)?
- Example 2: “Is behavioural activation by junior non-specialist workers as effective as a therapy by experienced psychologists?”
Spoiler alert for the questions above: yes and yes!
The research studies are presented in detail later.
Research studies published in scientific journals are known as “academic papers” (although most of them are accessed online rather than in paper form, and many of them are openly accessed not only by academics but also by the public). The evidence presented in academic papers can inform the work of professionals and the decisions of organisations and governments.
Two types of research are considered as the ‘gold standard’ of evidence: randomised controlled trials and systematic reviews.
Randomised controlled trials (RCTs)
Many research teams globally have evaluated behavioural activation by offering it to a group of people with depression and measuring their symptoms before and after a certain period of time using standardised questionnaires. Another group of people with depression is usually offered a different treatment to behavioural activation, or no treatment at all, and their symptoms are also measured before and after the same period of time using the same questionnaires. People are assigned to the two groups in a random way: neither the participants, nor the researchers know who will get which treatment. This type of evaluation is called a randomised controlled trial.
Systematic Reviews
Systematic reviews gather together all the academic papers about a particular topic; for example, whether behavioural activation is effective for different populations or whether its effects depend on how it is delivered. The researchers look at each study in great detail to decide whether it fits their topic and whether it is of good quality. Then they bring together the findings of all the included studies to answer their research question. The advantage of systematic reviews is that they look at a wider range of populations than single RCTs and can answer questions about groups of people with different characteristics.
Watch this explainer animation:
In the next two sections we will have a brief look at some examples of RCTs and systematic reviews of behavioural activation for depression. If you’d like to read more about any of these studies, there are some links for you to follow up in the resources sections.
Behavioural activation for different agesWe have robust evidence that behavioural activation is effective for adults with depression.
Two recent systematic reviews (Ekers et al, 2014; Uphoff et al 2020) brought together evidence from 26 and 53 studies respectively about the effectiveness of behavioural activation for adults. Both reviews concluded that behavioural activation is superior to usual care, and at least as good as, if not better than, cognitive behaviour therapy, supportive counselling, humanistic therapy and other brief psychotherapies. The mode of delivery – individual sessions, in groups or via self-help materials – did not influence the effect of behavioural activation. The Ekers et al (2014) review found a small but significant short-term superiority of behavioural activation against antidepressant medication.
A large RCT called COBRA (Richards et al, 2016) found that behavioural activation delivered by junior mental health workers was as good as cognitive behaviour therapy, a well established evidence-based intervention for depression, delivered by specialist therapists. The study showed that behavioural activation offers good value for money because it is cheaper but as effective as a more complex treatment for depression. This is important because highly trained and costly therapists are not available in some areas, and even if they are, they do not have the capacity to offer interventions for depression to all those who need them.
Behavioural activation with older adults
A systematic review of behavioural activation for depression in older adults (55 years plus) brought together the results from 18 randomised controlled trials and showed that behavioural activation can significantly reduce depressive symptoms in older people in the community compared to usual care or other treatments (Orgeta, Brede and Livingston, 2017). Quality of life, functioning and anxiety also improved alongside depression. Behavioural activation in most of the included studies was implemented by non-mental health specialists.
A seminal RCT called CASPER (Gilbody et al, 2017) found that older adults diagnosed with mild depression who received behavioural activation reported more improvement in their symptoms than those receiving usual care (the treatment for depression usually prescribed by a family doctor). Behavioural activation was delivered over the telephone to accommodate the more limited mobility of this age group and their initial reluctance to leave the home. This demonstrates the importance of having a flexible treatment approach that can overcome practical challenges when working with different sections of the population.
Behavioural activation with children and young people
Tindall et al. (2017) found that behavioural activation is likely to be effective in the treatment of depression in young people based on ten studies. An RCT done in the USA by McCauley et al (2016) with 60 adolescents showed comparable improvements in depression symptoms between those who received behavioural activation and those who received other ‘gold standard’ therapies. A more recent review by Martin and Oliver (2019) reported a large effect in favour of behavioural activation compared to other interventions and to no treatment.
The University of York in partnership with the Tees, Esk and Wear Valleys NHS Trust are carrying out a large programme of research, called ComBAT. This work evaluates brief behavioural activation in health services, schools and charities for young people aged 12-18 with mild to moderate depression. The ambition is to provide evidence for a scalable intervention that can be offered by different professionals and support staff in the community to enable them to change the trajectory of depression in young people. You can read more about it at combatdepression.org.
Resources
Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S (2014) Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLoS ONE 9(6): e100100. doi: 10.1371/journal.pone.0100100- Gilbody S, Lewis H, Adamson J, et la (2017). Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial. JAMA: Journal of the American Medical Association, 317(7):728-737. doi: 10.1001/jama.2017.0130.
- Martin F, Oliver T. (2019) Behavioral activation for children and adolescents: a systematic review of progress and promise. European Child and Adolescent Psychiatry. 28: 427. doi:10.1007/s00787-018-1126-z.
- McCauley E, Gudmundsen G, Schloredt K, Martell C, Phew I, Hubley S, Dimidjian S. (2016) The Adolescent Behavioral Activation Program: Adapting Behavioural Activation as a Treatment for Depression in Adolescence. Journal of Clinical Child and Adolescent Psychology, 45(3), 291-304. doi: 10.1080/15374416.2014.979933.
- Orgeta V, Brede J, Livingston G. (2017) Behavioural activation for depression in older people: systematic review and meta-analysis. British Journal of Psychiatry, 211(5):274-279. doi: 10.1192/bjp.bp.117.205021.
- Richards DA, Ekers D, McMillan D, et al (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet, 388(10047):871-80. doi: 10.1016/S0140-6736(16)31140-0.
- Tindall L, Mikocka-Walus A, McMillan D, Wright B, Hewitt C, Gascoyne S. (2017). Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis. Psychology and Psychotherapy, 90(4):770-796. https://doi: 10.1111/papt.12121.
- Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, Samaan Z, Richards D, Meader N, Churchill R. (2020). Behavioural activation therapy for depression in adults. Cochrane Database of Systematic Reviews, Issue 7. Art. No.:CD013305. doi: 10.1002/14651858.CD013305.pub2
Behavioural activation for different culturesIt is important to look at behavioural activation through a cultural lens to ensure that it remains relevant and helpful across and within different cultures.
Why is culture important to consider in behavioural activation?
The starting point of behavioural activation is to find out what we value about our lives, about ourselves and about those around us, and then to identify and schedule enjoyable and purposeful activities linked to these values. The culture in which we grow up, such as our religion, ethnicity, language, and traditions, can shape our values and affect what activities that are open, acceptable, and feasible for us as part of behavioural activation. Attitudes towards mental health and how depression is expressed may also vary from culture to culture.
How can behavioural activation be culturally adapted?
Cultural adaptation of behavioural activation often requires translation of resources into a different language, not only in terms of the words used, but also to capture the nuances of the language, which may be different even across English speaking countries. The other aspect of adaptation relates to the visual style of the materials, what images we use and how a specific group of people is represented. Finally, examples and metaphors that we often use to explain behavioural activation may make sense in one culture but not another.
The research evidence
Two systematic reviews suggest that behavioural activation is effective for people from different cultural backgrounds.
-
- First, Anderson et al (2015) reviewed evidence from 16 studies in which therapies including behavioural activation were adapted for people with depression and anxiety from different faiths. The results suggest that faith-adapted therapy may outperform standard therapy (which has not been culturally adapted) and also yields better outcomes than no therapy or usual care (which may be another therapy or medication).
- Second, Lehmann and Bordlein (2020) reviewed 17 studies of behavioural activation adapted to include appropriate cultural symbols, values, metaphors, and culturally appropriate terms. The review found that culturally adapted behavioural activation resulted in medium to large improvements in depression symptoms compared to alternative approaches.
It is interesting that these two reviews did not differentiate between studies that looked at culturally adapted behavioural activation for minority populations within a country (e.g. Latinos within the USA), and studies which took place in countries where the culture or religion was mainstream and dominant (e.g. Christianity in the USA and Islam in Iran).
Can you think why it may be important to look at behavioural activation for a specific culture separately when the people who use it belong to a migrant community in a country, rather than when we use it with different cultures in their own native countries?
Resources
- Anderson N, Heywood-Everett S, Siddiqi N, Wright J, Meredith J, McMillan D (2015). Faith-adapted psychological therapies for depression and anxiety: Systematic review and meta-analysis. Journal of Affective Disorders, 176, 183-96, e100100. doi: 10.1016/j.jad.2015.01.019.
- Lehmann DC, Bördlein C (2020). A Systematic Review of Culturally Adapted Behavioral Activation Treatments for Depression. Research on Social Work Practice, 30(6), 688-702. doi: 10.1177/1049731520915635.
Research is important because it provides evidence about whether behavioural activation works to improve depression and for whom it may work better.
Research studies are designed to answer specific questions. Here are two examples:
- Example 1: “Is behavioural activation effective for the treatment of depression in adults compared to usual care (which can include antidepressant medication or other forms of support)?
- Example 2: “Is behavioural activation by junior non-specialist workers as effective as a therapy by experienced psychologists?”
Spoiler alert for the questions above: yes and yes!
The research studies are presented in detail later.
Research studies published in scientific journals are known as “academic papers” (although most of them are accessed online rather than in paper form, and many of them are openly accessed not only by academics but also by the public). The evidence presented in academic papers can inform the work of professionals and the decisions of organisations and governments.
Two types of research are considered as the ‘gold standard’ of evidence: randomised controlled trials and systematic reviews.
Randomised controlled trials (RCTs)
Many research teams globally have evaluated behavioural activation by offering it to a group of people with depression and measuring their symptoms before and after a certain period of time using standardised questionnaires. Another group of people with depression is usually offered a different treatment to behavioural activation, or no treatment at all, and their symptoms are also measured before and after the same period of time using the same questionnaires. People are assigned to the two groups in a random way: neither the participants, nor the researchers know who will get which treatment. This type of evaluation is called a randomised controlled trial.
Systematic Reviews
Systematic reviews gather together all the academic papers about a particular topic; for example, whether behavioural activation is effective for different populations or whether its effects depend on how it is delivered. The researchers look at each study in great detail to decide whether it fits their topic and whether it is of good quality. Then they bring together the findings of all the included studies to answer their research question. The advantage of systematic reviews is that they look at a wider range of populations than single RCTs and can answer questions about groups of people with different characteristics.
Watch this explainer animation:
In the next two sections we will have a brief look at some examples of RCTs and systematic reviews of behavioural activation for depression. If you’d like to read more about any of these studies, there are some links for you to follow up in the resources sections.
We have robust evidence that behavioural activation is effective for adults with depression.
Two recent systematic reviews (Ekers et al, 2014; Uphoff et al 2020) brought together evidence from 26 and 53 studies respectively about the effectiveness of behavioural activation for adults. Both reviews concluded that behavioural activation is superior to usual care, and at least as good as, if not better than, cognitive behaviour therapy, supportive counselling, humanistic therapy and other brief psychotherapies. The mode of delivery – individual sessions, in groups or via self-help materials – did not influence the effect of behavioural activation. The Ekers et al (2014) review found a small but significant short-term superiority of behavioural activation against antidepressant medication.
A large RCT called COBRA (Richards et al, 2016) found that behavioural activation delivered by junior mental health workers was as good as cognitive behaviour therapy, a well established evidence-based intervention for depression, delivered by specialist therapists. The study showed that behavioural activation offers good value for money because it is cheaper but as effective as a more complex treatment for depression. This is important because highly trained and costly therapists are not available in some areas, and even if they are, they do not have the capacity to offer interventions for depression to all those who need them.
Behavioural activation with older adults
A systematic review of behavioural activation for depression in older adults (55 years plus) brought together the results from 18 randomised controlled trials and showed that behavioural activation can significantly reduce depressive symptoms in older people in the community compared to usual care or other treatments (Orgeta, Brede and Livingston, 2017). Quality of life, functioning and anxiety also improved alongside depression. Behavioural activation in most of the included studies was implemented by non-mental health specialists.
A seminal RCT called CASPER (Gilbody et al, 2017) found that older adults diagnosed with mild depression who received behavioural activation reported more improvement in their symptoms than those receiving usual care (the treatment for depression usually prescribed by a family doctor). Behavioural activation was delivered over the telephone to accommodate the more limited mobility of this age group and their initial reluctance to leave the home. This demonstrates the importance of having a flexible treatment approach that can overcome practical challenges when working with different sections of the population.
Behavioural activation with children and young people
Tindall et al. (2017) found that behavioural activation is likely to be effective in the treatment of depression in young people based on ten studies. An RCT done in the USA by McCauley et al (2016) with 60 adolescents showed comparable improvements in depression symptoms between those who received behavioural activation and those who received other ‘gold standard’ therapies. A more recent review by Martin and Oliver (2019) reported a large effect in favour of behavioural activation compared to other interventions and to no treatment.
The University of York in partnership with the Tees, Esk and Wear Valleys NHS Trust are carrying out a large programme of research, called ComBAT. This work evaluates brief behavioural activation in health services, schools and charities for young people aged 12-18 with mild to moderate depression. The ambition is to provide evidence for a scalable intervention that can be offered by different professionals and support staff in the community to enable them to change the trajectory of depression in young people. You can read more about it at combatdepression.org.
Resources
- Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S (2014) Behavioural Activation for Depression; An Update of Meta-Analysis of Effectiveness and Sub Group Analysis. PLoS ONE 9(6): e100100. doi: 10.1371/journal.pone.0100100
- Gilbody S, Lewis H, Adamson J, et la (2017). Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial. JAMA: Journal of the American Medical Association, 317(7):728-737. doi: 10.1001/jama.2017.0130.
- Martin F, Oliver T. (2019) Behavioral activation for children and adolescents: a systematic review of progress and promise. European Child and Adolescent Psychiatry. 28: 427. doi:10.1007/s00787-018-1126-z.
- McCauley E, Gudmundsen G, Schloredt K, Martell C, Phew I, Hubley S, Dimidjian S. (2016) The Adolescent Behavioral Activation Program: Adapting Behavioural Activation as a Treatment for Depression in Adolescence. Journal of Clinical Child and Adolescent Psychology, 45(3), 291-304. doi: 10.1080/15374416.2014.979933.
- Orgeta V, Brede J, Livingston G. (2017) Behavioural activation for depression in older people: systematic review and meta-analysis. British Journal of Psychiatry, 211(5):274-279. doi: 10.1192/bjp.bp.117.205021.
- Richards DA, Ekers D, McMillan D, et al (2016). Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet, 388(10047):871-80. doi: 10.1016/S0140-6736(16)31140-0.
- Tindall L, Mikocka-Walus A, McMillan D, Wright B, Hewitt C, Gascoyne S. (2017). Is behavioural activation effective in the treatment of depression in young people? A systematic review and meta-analysis. Psychology and Psychotherapy, 90(4):770-796. https://doi: 10.1111/papt.12121.
- Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, Samaan Z, Richards D, Meader N, Churchill R. (2020). Behavioural activation therapy for depression in adults. Cochrane Database of Systematic Reviews, Issue 7. Art. No.:CD013305. doi: 10.1002/14651858.CD013305.pub2
It is important to look at behavioural activation through a cultural lens to ensure that it remains relevant and helpful across and within different cultures.
Why is culture important to consider in behavioural activation?
The starting point of behavioural activation is to find out what we value about our lives, about ourselves and about those around us, and then to identify and schedule enjoyable and purposeful activities linked to these values. The culture in which we grow up, such as our religion, ethnicity, language, and traditions, can shape our values and affect what activities that are open, acceptable, and feasible for us as part of behavioural activation. Attitudes towards mental health and how depression is expressed may also vary from culture to culture.
How can behavioural activation be culturally adapted?
Cultural adaptation of behavioural activation often requires translation of resources into a different language, not only in terms of the words used, but also to capture the nuances of the language, which may be different even across English speaking countries. The other aspect of adaptation relates to the visual style of the materials, what images we use and how a specific group of people is represented. Finally, examples and metaphors that we often use to explain behavioural activation may make sense in one culture but not another.
The research evidence
Two systematic reviews suggest that behavioural activation is effective for people from different cultural backgrounds.
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- First, Anderson et al (2015) reviewed evidence from 16 studies in which therapies including behavioural activation were adapted for people with depression and anxiety from different faiths. The results suggest that faith-adapted therapy may outperform standard therapy (which has not been culturally adapted) and also yields better outcomes than no therapy or usual care (which may be another therapy or medication).
- Second, Lehmann and Bordlein (2020) reviewed 17 studies of behavioural activation adapted to include appropriate cultural symbols, values, metaphors, and culturally appropriate terms. The review found that culturally adapted behavioural activation resulted in medium to large improvements in depression symptoms compared to alternative approaches.
It is interesting that these two reviews did not differentiate between studies that looked at culturally adapted behavioural activation for minority populations within a country (e.g. Latinos within the USA), and studies which took place in countries where the culture or religion was mainstream and dominant (e.g. Christianity in the USA and Islam in Iran).
Can you think why it may be important to look at behavioural activation for a specific culture separately when the people who use it belong to a migrant community in a country, rather than when we use it with different cultures in their own native countries?
Resources
- Anderson N, Heywood-Everett S, Siddiqi N, Wright J, Meredith J, McMillan D (2015). Faith-adapted psychological therapies for depression and anxiety: Systematic review and meta-analysis. Journal of Affective Disorders, 176, 183-96, e100100. doi: 10.1016/j.jad.2015.01.019.
- Lehmann DC, Bördlein C (2020). A Systematic Review of Culturally Adapted Behavioral Activation Treatments for Depression. Research on Social Work Practice, 30(6), 688-702. doi: 10.1177/1049731520915635.
Wrapping up Section 3
A summary of what has been covered this week and a quiz relating to this.
Take-home messageIn section 3, we have seen how behavioural activation can be applied.
We have explored each of the key components of BA in turn: functional analysis, activity scheduling, setting goals and relapse prevention. We have also looked at how research in the form of randomised controlled trials and systematic reviews have demonstrated that behavioural activation can work for a range of age groups and cultures.
The take-home message is:
-
Behavioural activation aims to reduce avoidance, rumination, procrastination, and withdrawal, and at the same time increase enjoyable, purposeful and rewarding activities that connect with people and things that are important for an individual.
Take a moment to reflect on the ideas that have been explored in this section:
- What did you find particularly interesting?
- What are the main things you have discovered?
- Were there any parts you found challenging?
- What would you like to find out more about?
- What have you learnt that you might put into practice?
In section 3, we have seen how behavioural activation can be applied.
We have explored each of the key components of BA in turn: functional analysis, activity scheduling, setting goals and relapse prevention. We have also looked at how research in the form of randomised controlled trials and systematic reviews have demonstrated that behavioural activation can work for a range of age groups and cultures.
The take-home message is:
-
Behavioural activation aims to reduce avoidance, rumination, procrastination, and withdrawal, and at the same time increase enjoyable, purposeful and rewarding activities that connect with people and things that are important for an individual.
Take a moment to reflect on the ideas that have been explored in this section:
- What did you find particularly interesting?
- What are the main things you have discovered?
- Were there any parts you found challenging?
- What would you like to find out more about?
- What have you learnt that you might put into practice?
This short quiz aims to help you think about what you’ve been learning and if there is anything you’d like to go back to review or explore further.
The quiz is optional as a learning tool.
Question 1: What is the purpose of functional analysis in behavioural activation?
Select all the answers you think are correct.
- It helps us understand what situations in a person’s life trigger feelings of unhappiness.
- It helps us understand what the person avoids doing, or is doing less, or is doing more than usual to cope and deal with the situation
- It helps us understand how the person’s avoidance and activity give them, or deprive them of, emotional rewards.
- It helps us understand what negative thoughts maintain the person’s depression
Question 2: Activity scheduling encourages the following types of activities
Select all the answers you think are correct.
- Enjoyable activities
- Routine activities
- Challenging activities
- Thinking things over and over
Question 3: Research evidence suggests that behavioural activation is
Select all the answers you think are correct.
- Better than usual care
- Less costly than other therapies
- More effective when delivered by mental health specialists
- More effective for certain cultures
Question 4: What information is included in the weekly activity schedule as part of behavioural activation?
Select all the answers you think are correct.
- How enjoyable activities are on a 0-10 scale
- How happy or sad we feel after an activity on a 0-10 scale
- Which activities are completed
- What activities we did without scheduling
Question 1: What is the purpose of functional analysis in behavioural activation?
- It helps us understand what situations in a person’s life trigger feelings of unhappiness.
- Through a series of questions, a functional analysis finds out what situations in a person’s life trigger feelings of unhappiness, worry, shame or frustration (Antecedents).
- It helps us understand what the person avoids doing, or is doing less, or is doing more than usual to cope and deal with the situation
- Through a series of questions, a functional analysis finds out what the person avoids doing, or is doing less, or is doing more than usual to cope and deal with the situation (Behaviours).
- It helps us understand how the person’s avoidance and activity give them, or deprive them of, emotional rewards.
- A functional analysis finds out how the person’s avoidance or activity give them or deprive them of emotional rewards (Consequences).
It helps us understand what negative thoughts maintain the person’s depression
- Understanding what negative thoughts maintain the person’s depression is not a feature of behavioural activation, although it is used in cognitive therapy for depression. Negative thinking is important in depression, but even without focusing on negative thoughts, these tend to diminish automatically as a consequence of behavioural activation when symptoms of depression improve.
Question 2: Activity scheduling encourages the following types of activities
- Enjoyable activities
- Enjoyable activities are important in behavioural activation because they reinstate our interest and pleasure in life.
- Routine activities
- Routine activities are important in behavioural activation because they lead to a sense of achievement and satisfaction, they override avoidance and procrastination and they connect with things that are important for our life and wellbeing like work, family and self-care.
- Challenging activities
- Challenging but manageable activities are important in behavioural activation because they lead to a sense of achievement and satisfaction.
Thinking things over and over
- Thinking things over and over can be a form of rumination which feeds into depression therefore is not encouraged by behavioural activation.
Question 3: Research evidence suggests that behavioural activation is
- Better than usual care
- Two recent systematic reviews (Ekers et al, 2014; Uphoff et al 2020) brought together evidence from 26 and 53 studies respectively about the effectiveness of behavioural activation for adults. Both reviews concluded that behavioural activation is superior to usual care.
- Less costly than other therapies
- A large RCT called COBRA (Richards et al, 2016) found that behavioural activation offers good value for money because it is cheaper but as effective as a more complex treatment for depression.
More effective when delivered by mental health specialists
- A large RCT called COBRA (Richards et al, 2016) found that behavioural activation delivered by junior mental health workers was as good as cognitive behaviour therapy, a well-established evidence-based intervention for depression delivered by specialist therapists.
More effective for certain cultures
- Two systematic reviews suggest that behavioural activation is effective for people from different cultural backgrounds. First, Anderson et al (2015) reviewed evidence from 16 studies in which therapies including behavioural activation were adapted for people with depression and anxiety from different faiths. Second, Lehmann and Bordlein (2020) reviewed 17 studies of behavioural activation adapted to include appropriate cultural symbols, values, metaphors and culturally appropriate terms.
Question 4: What information is included in the weekly activity schedule as part of behavioural activation?
- How enjoyable activities are on a 0-10 scale
- As we complete our scheduled activities, we assign a score to each one: these scores represent how much pleasure and a sense of achievement each activity gives us and how much we feel it connects us with important areas of life. We rate each activity on a scale of 0-10: 0 = no enjoyment/achievement/connection, 10 = great enjoyment/achievement/connection.
How happy or sad we feel after an activity on a 0-10 scale
- We only attribute scores of enjoyment, sense of achievement and connection to each activity, not how happy or sad we feel after the activity; this is because we are interested in sustained changes in happiness or sadness which happen cumulatively as a result of many activities over the course of weeks.
- Which activities are completed
- The weekly activity schedule tells us which activities are completed; it is more important to schedule fewer activities that can be completed rather than the cram many activities in the weekly calendar.
- What activities we did without scheduling
- In behavioural activation we record not only what we scheduled to do, but also what we spontaneously or routinely do each day.
How did you get on?
We hope you found the quiz a helpful way to reflect on everything you have learnt so far.
End of the BA learning resources
You’ve reached the end of the BA learning resources! Many congratulations!!
We hope you found it enjoyable, as well as informative.
Final summaryDepression is a clinical condition that persists over time and prevents us from enjoying and getting the most out of life. Behavioural activation is an effective brief intervention to help depression across different age groups and cultures.
In the first section, we started this course by describing the key symptoms of depression and the different options for treatment, including psychological therapies with a professional, self-directed therapy and medication. We differentiated between depression and normal mood fluctuations that everyone experiences from time to time. Simple questionnaires can be used by professionals to recognise depression; these should not be used for diagnosis or to screen whole populations, but to decide whether people who experience symptoms of persistently low mood or irritability, and have lost interest in life, need further assessment and treatment as necessary.
In section 2, we saw how closely mood and behaviour are linked. The A-B-C model describes people’s natural tendencies to avoid things that are difficult or unstimulating, and to keep doing things that are enjoyable and fulfilling. Depression drains us of joy, energy, and motivation; therefore, we avoid doing things, or we do less of what is good for us, because we can’t face it or don’t feel like it. Behavioural activation introduces the idea that we should not wait until we feel better in order to do things that we enjoy and make us feel good about ourselves; we do them in order to feel better. This is called purpose-driven rather than mood-driven activity.
In the final section, we introduced you to the practical elements of behavioural activation. The first step is to understand what we avoid, put off doing, or are doing less than usual because of depression. Then we use a weekly calendar to schedule and complete enjoyable and purposeful activities that connect us with people and things in life that are important to us. The activities are graded so that they are not overwhelming, but they need to introduce change, challenge, and variety in what we normally do. Research has given us evidence to support behavioural activation as an effective treatment of depression for working-age adults, older adults, children, and adolescents across different cultures.
Download a short pdf Introduction to Behavioural Activation with all the key take-away messages and tips from this BA Learning Resource
Depression is a clinical condition that persists over time and prevents us from enjoying and getting the most out of life. Behavioural activation is an effective brief intervention to help depression across different age groups and cultures.
In the first section, we started this course by describing the key symptoms of depression and the different options for treatment, including psychological therapies with a professional, self-directed therapy and medication. We differentiated between depression and normal mood fluctuations that everyone experiences from time to time. Simple questionnaires can be used by professionals to recognise depression; these should not be used for diagnosis or to screen whole populations, but to decide whether people who experience symptoms of persistently low mood or irritability, and have lost interest in life, need further assessment and treatment as necessary.
In section 2, we saw how closely mood and behaviour are linked. The A-B-C model describes people’s natural tendencies to avoid things that are difficult or unstimulating, and to keep doing things that are enjoyable and fulfilling. Depression drains us of joy, energy, and motivation; therefore, we avoid doing things, or we do less of what is good for us, because we can’t face it or don’t feel like it. Behavioural activation introduces the idea that we should not wait until we feel better in order to do things that we enjoy and make us feel good about ourselves; we do them in order to feel better. This is called purpose-driven rather than mood-driven activity.
In the final section, we introduced you to the practical elements of behavioural activation. The first step is to understand what we avoid, put off doing, or are doing less than usual because of depression. Then we use a weekly calendar to schedule and complete enjoyable and purposeful activities that connect us with people and things in life that are important to us. The activities are graded so that they are not overwhelming, but they need to introduce change, challenge, and variety in what we normally do. Research has given us evidence to support behavioural activation as an effective treatment of depression for working-age adults, older adults, children, and adolescents across different cultures.
Download a short pdf Introduction to Behavioural Activation with all the key take-away messages and tips from this BA Learning Resource
This is an optional final test step covering the entire course content, it is designed to help you verify your understanding.
Question 1: Everyone experiences depression in a different way. Which two key symptoms do professionals check for first, when they want to make a diagnosis of depression?
Select all the answers you think are correct.
- Feeling sad or angry a lot of the time
- Having difficulties sleeping
- Losing interest and pleasure in doing things
- Feeling tired all the time, even when you do not do much
Question 2: What are the advantages of using standard questionnaires as screening tools for depression?
Select all the answers you think are correct.
- They are brief and can be completed without specialist training.
- They can be used to diagnose depression in the absence of a mental health professional.
- They can remain valid measures of depression after translation in different languages.
- They should be used to routinely screen everyone for depression in the general population.
Question 3: A cartoon walks through four different doors on separate occasions. Different things happen as the cartoon walks through each door. The doors are a metaphor for behaviour. Which doors are likely to maintain depression?
Select all the answers you think are correct.
- Our cartoon meets someone who gives them a treasure chest.
- Our cartoon meets someone who gives them a kick.
- Our cartoon meets someone who has a magic spell that gives relief from pain but only as long as the cartoon remains by that door.
- Our cartoon meets nobody and gets nothing.
Question 4: How does depression affect our behaviour?
Select all the answers you think are correct.
- We tend to do things impulsively without thinking about them
- We put off doing difficult or challenging tasks
- We let our mood drive what we do, so that we only do things if we feel like them
- We tend to do things we find enjoyable rather than things that they are boring or routine
Question 5: How does behavioural activation work to help improve symptoms of depression?
Select all the answers you think are correct.
- It distracts us from our negative feelings
- It increases emotional rewards like pleasure and a sense of achievement
- It overrides avoidance and procrastination
- It keeps us safe from doing things that are difficult and challenging
Question 6: What does activity scheduling involve in the context of behavioural activation?
- Making a long list of things to-do and tick them off as we are doing them
- Monitoring how much enjoyment and a sense of achievement each scheduled activity gives us
- Including people and areas of life that are important to us
- Using a weekly calendar to schedule activities at a specific day and at a specific time.
Question 7: What type of activities would you advise someone with depression to schedule in their weekly calendar as part of behavioural activation?
Select all the answers you think are correct.
-
- Activities that connect with people and things that are important to them
- A mixture of pleasures and routines
- Naps through the day so that they have more energy
- Activities that are different to what they normally do
Question 8: Depression affects our motivation to do things. How can we help someone with depression complete their scheduled activities when they do not feel like doing them?
Select all the answers you think are correct.
- Only schedule activities that the person feels like doing.
- Ask family and friends to complete activities for the person.
- Start with activities that speak to the person’s strengths, interests and skills.
- Focus on one important activity and break it down into a series of smaller activities.
Question 9: After depression improves, how can we use behavioural activation to maintain our gains and prevent depression in the future?
Select all the answers you think are correct.
- Understand what activities are rewarding for us in terms of giving us pleasure and a sense of achievement
- Recognise negative thoughts and challenge them
- Schedule enjoyable and purposeful activities every week
- Forget about depression and never look back
Question 10: What does research evidence tell us about the value of behavioural activation for depression?
- Behavioural activation is more effective but also more costly than other therapies
- Behavioural activation works as well as and is cheaper than other therapies
- Behavioural activation is more effective when delivered by highly experienced mental health specialists
- Behavioural activation can be easily adapted for people from different cultures
Question 1: Everyone experiences depression in a different way. Which two key symptoms do professionals check for first, when they want to make a diagnosis of depression?
- Feeling sad or angry a lot of the time
- Feeling sad or angry a lot of the time is one of two key symptoms of depression that professionals check out first, according to international diagnostic manuals, the other symptom being “loss of interest or pleasure”.
Having difficulties sleeping
- Having difficulties sleeping can be a symptom of depression but also of many other conditions, so we check for sleeping difficulties after we check for low mood and loss of interest or pleasure.
- Losing interest and pleasure in doing things
- Losing interest and pleasure in doing things is one of two key symptoms of depression that professionals check out first, according to international diagnostic manuals, the other symptom being “low mood”.
Feeling tired all the time, even when you do not do much
- Feeling excessively tired can be a symptom of depression but it can also be caused by many other physical and mental health conditions; therefore, we check for it after we have established that depression may be the likely cause of tiredness linked to low mood and loss of interest or pleasure.
Question 2: What are the advantages of using standard questionnaires as screening tools for depression?
- They are brief and can be completed without specialist training.
- Questionnaires that screen for depression have a few brief questions, can be completed directly by the person who presents with symptoms and have a standard scoring system with pre-determined cut-off points that suggest whether depression is likely to be present and whether it is likely to be mild, moderate or severe.
They can be used to diagnose depression in the absence of a mental health professional.
- Standardised questionnaires only screen for the likelihood of depression and should not be used for a formal diagnosis of depression, which requires a comprehensive assessment by a professional with appropriate training.
- They can remain valid measures of depression after translation in different languages.
- Many standardised questionnaires that screen for depression have been adapted to different languages. With PHQ-9 as a case in point, validation studies showed that it remained a valid measure of depression after translation, but depression symptom scores were not always equivalent across different languages.
They should be used to routinely screen everyone for depression in the general population.
- Routine screening for depression in the general population is not recommended because normal mood variations can mislead us in thinking that people may have depression when they are not. Screening tools are used as a way of gauging the likelihood and severity of depression when people feel that their low mood persists for a long time and has a major impact in their lives.
Question 3: A cartoon walks through four different doors on separate occasions. Different things happen as the cartoon walks through each door. The doors are a metaphor for behaviour. Which doors are likely to maintain depression?
Our cartoon meets someone who gives them a treasure chest.
- Meeting someone who gives our cartoon a treasure chest is an analogy for positive reinforcement; having a reward by walking through that door is likely to encourage the cartoon to go back. In this case, the door is a metaphor for an emotionally rewarding activity, i.e. something that leads to enjoyment or a sense of achievement. In the context of behaviour, walking through a “rewarding” door can be helpful.
- Our cartoon meets someone who gives them a kick.
- Meeting someone who gives our cartoon a kick sounds like punishment; having pain by walking through that door is likely to make the cartoon avoid that door. Even worse, a “painful” door may discourage our cartoon from walking through ANY door, including the one with the treasure.
- Avoiding things that we find emotionally or physically painful because of depression, for example, due to bad memories, self-reproach, or exhaustion, is a natural response; however, avoidance can indirectly maintain depression because it deprives us of opportunities to have emotionally rewarding experiences and to connect with people and things that matter.
- Our cartoon meets someone who has a magic spell that gives relief from pain but only as long as the cartoon remains by that door.
- Our cartoon meeting someone with a magic spell that gives relief from pain is a metaphor for negative reinforcement; the cartoon is likely to walk through that door every time they need the magic spell to make emotional or physical pain disappear, but as soon as they move away from the door, the pain reappears. Standing by, or repeatedly walking through the “pain relief” door prevents our cartoon from reaching the door with the treasure.
- In the context of depression, distraction or procrastination may temporarily work to provide relief from feeling overwhelmed or from doing something difficult or tedious. Distraction and procrastination simply delay bad/negative feelings and indirectly maintain depression because they deprive us of opportunities to experience good/positive feelings.
- Our cartoon meets nobody and gets nothing.
- Meeting nobody and getting nothing is a metaphor for the absence of any emotional rewards, or else, the absence of positive reinforcement. This makes the cartoon more likely to stop walking through that door; not because they deliberately avoid it, but because there is not point to it and they no longer care.
- Absence of positive reinforcement is the key mechanism that maintains depression and the “nobody and nothing” door is a metaphor that illustrates how depression makes people stop or reduce activities because they see no point in them or they no longer care.
Question 4: How does depression affect our behaviour?
We tend to do things impulsively without thinking about them
- Doing things impulsively without thinking about them is not typical of depression. On the contrary, depression tends to make people ruminate and overthink things.
- We put off doing difficult or challenging tasks
- Putting off doing difficult or challenging tasks is characteristic of depression; this maintains depression because difficult or challenging tasks, when graded properly, can give people a great sense of achievement.
- We let our mood drive what we do, so that we only do things if we feel like them
- Letting our mood drive what what we do, so that we only do things if we feel like them, is classic depression trap. Mood-driven behaviour maintains depression. Behavioural activation proposes that we don’t wait until we feel better in order to do things, but we do things in order to feel better.
We tend to do things we find enjoyable rather than things that they are boring or routine
- Typically in depression, we tend to stop doing things we find enjoyable, or do less of what we used to find enjoyable. Also, sometimes in depression, there is an imbalance between things that we want to do and things that we have to do as routines.
Question 5: How does behavioural activation work to help improve symptoms of depression?
It distracts us from our negative feelings
- Behavioural activation does not work by simply distracting us from our negative feelings but by generating positive feelings.
- It increases emotional rewards like pleasure and a sense of achievement
- Indeed behavioural activation works by increasing emotional rewards like pleasure and a sense of achievement through weekly scheduling of enjoyable and purposeful activities that connect us with people and things that matter.
- It overrides avoidance and procrastination
- Behavioural activation works by overriding avoidance and procrastination through weekly scheduling of purposeful and enjoyable activities.
It keeps us safe from doing things that are difficult and challenging
- Behavioural activation encourages us to do things that are difficult and challenging but in a graded way so that they achievable. A sense of achievement comes from managing to complete something difficult.
Question 6: What does activity scheduling involve in the context of behavioural activation?
Making a long list of things to-do and tick them off as we are doing them
- A long list of things to do can feel overwhelming and also lacks structure; therefore a calendar is preferable because the activities are visually spread out and can be scheduled at a specific day and time that the person is more likely to achieve them.
- Monitoring how much enjoyment and a sense of achievement each scheduled activity gives us
- As we complete our scheduled activities, we assign a score to each one: these scores represent how much pleasure and a sense of achievement each activity gives us. We rate each activity on a scale of 0-10: 0 = no enjoyment/achievement, 10 = great enjoyment/achievement.
- Including people and areas of life that are important to us
- The starting point of activity scheduling is to find out what things are important for each person: what they value about themselves and in other people, who matters to them, and what things take priority in their lives.
- This is like a jigsaw puzzle, where different pieces – such as family, relationships, work, school, physical health, mental health, self-image, knowledge, adventure, creativity, security, autonomy, charity – make up our life.
- Using a weekly calendar to schedule activities at a specific day and at a specific time
- We schedule activities at a specific day and at a specific time when the person will find it easier to achieve them; for example, when family members are around to help or to fit around work commitments.
Question 7: What type of activities would you advise someone with depression to schedule in their weekly calendar as part of behavioural activation?
- Activities that connect with people and things that are important to them
- Activities that connect with what is important to us are meaningful and more likely to be emotionally rewarding.
- A mixture of pleasures and routines
- Within and across different areas of life, activities fulfil different purposes, depending on whether they are things that:
- 1. We enjoy and want to do; these are day-to-day pleasures.
- 2. We have to do and are necessary; these are routine tasks.
- Behavioural activation includes a mix of pleasures and routines; pleasures aims to reinstate our interest in and enjoyment of life, whereas routines can introduce purpose and a sense of achievement.
Naps through the day so that they have more energy
- Although sleeping well is important, oversleeping or sleeping throughout the day is counterproductive in the context of depression because it feeds into inactivity, sluggishness and tiredness.
- Activities that are different to what they normally do
- Introducing variance in activity is important so that people find things that are enjoyable in the face of depression and also to give a sense of achievement as new things take more effort than familiar things.
Question 8: Depression affects our motivation to do things. How can we help someone with depression complete their scheduled activities when they do not feel like doing them?
Only schedule activities that the person feels like doing.
- In behavioural activation we don’t just schedule activities that the person feels like doing, because the principle of behavioural activation is to kick-start motivation through action (we don’t wait to feel better in order to do something, but we do it so that we can feel better).
Ask family and friends to complete activities for the person.
- Although it is important for family and friends to support someone with depression, this support should enable the person to complete their own activities rather than the family or friends taking over from the person.
- Start with activities that speak to the person’s strengths, interests and skills.
- Activities that speak to our strengths, interests and skills are more likely to connect with what matters to us and can be inherently motivating and a good starting point for activity scheduling in the face of depression.
- Focus on one important activity and break it down into a series of smaller activities.
- If the person is struggling, then having a small goal which can be achieved with less steps can be a real mood booster and gives encouragement to keep going. More challenging and longer-term goals may need more steps. This process is called grading. Focus on one important activity and allow enough time and opportunities to complete the activity during the week. It is more important to schedule fewer activities that can be completed rather than the cram many activities in the weekly calendar. Break down the activities into even more steps and repeat them until they are completed with relative ease before moving to more difficult steps.
Question 9: After depression improves, how can we use behavioural activation to maintain our gains and prevent depression in the future?
- Understand what activities are rewarding for us in terms of giving us pleasure and a sense of achievement
- Understanding what activities are rewarding for us in terms of giving us pleasure and a sense of achievement is an important part of preventing depression in the future. This starts with a reflective exercise: looking back to how we felt before beginning behavioural activation, what we have learnt along the way and what activities made the difference to how we feel now.
Recognise negative thoughts and challenge them
- Recognising negative thoughts and challenging them is not a feature of behavioural activation but it is a process commonly used in cognitive therapy for depression.
- Schedule enjoyable and purposeful activities every week
- To maintain our gains with behavioural activation we need to keep doing enjoyable, purposeful and rewarding weekly activities.
Forget about depression and never look back
- A typical staying well plan includes looking back to what we have learnt, as well as looking forward to what may happen and how to deal with it.
Question 10: What does research evidence tell us about the value of behavioural activation for depression?
Behavioural activation is more effective but also more costly than other therapiesBehavioural activation works as well as and is cheaper than other therapiesBehavioural activation is more effective when delivered by highly experienced mental health specialists- Behavioural activation can be easily adapted for people from different cultures
- Two systematic reviews suggest that behavioural activation is effective for people from different cultural backgrounds.
How did you get on?
We hope you found the quiz a helpful way to reflect on everything you have learnt.
Good wishes for the future from all of us. If you found our training helpful please recommend it to your colleagues and friends.