1. Behavioral Activation (Adapted from C.Martell’s BA Manual & Trainings)
Behavioral activation is a basic coping strategy that can have a tremendous effect on a person’s mood.
When we have clients that feel depressed or anxious, they may be less likely to do the things they enjoy or avoid other potentially pleasurable activities.
A consequence of this is often a worsening of mood, feeling more detached from others, and an increase in anxiety.
In addition, as people feel more and more isolated, their depressive symptoms become more moderate or severe.
Abigail Eiler, LMSW, CMHP, QMHP, ASIST-11 Registered Trainer
October 16, 2015

2. Behavioral Health in PC
“In 2010, 20% of all visits to primary care physicians included at least one of the following mental health indicators: depression screening, counseling, a mental health diagnosis or reason for visit, psychotherapy, or provision of a psychotropic drug.” (2010, National Ambulatory Medical Care Survey).
“…primary care physicians remain the point of entry into the behavioral health system, even when managed behavioral health care organizations [such as MHNet] are in place.” (2000, American Psychiatric Association’s (APA) Practice Guideline).
Patients are less likely to follow-up on behavioral health referrals. Completing a brief intervention during a primary care encounter will help promote healthy, effective behaviors can improve mental health outcomes.

3. What is Behavioral Activation?
Brief psychosocial-spiritual therapeutic approach.
Developed and identified as a 3rd Generation behavioral therapy.
Based on Charles Fester’s Functional Analysis of Depression (70s).
Structured and addresses problems and behaviors associated with various disorders:
*Depression
Anxiety
PTSD
Based on premise that problems in vulnerable individuals' lives and behavioral responses reduce ability to experience positive reward from their environments
Aims to systematically increase activation such that patients may experience greater contact with sources of reward in their lives and solve life problems
Focuses directly on activation and on processes that inhibit activation, such as escape and avoidance behaviors and ruminative thinking

4. Theory
The behavioral activation model suggests that negative life events such as grief, trauma, daily stressors, or a genetic predisposition to depression can lead to a person having too little positive reinforcement. Additionally, a person might turn to unhealthy behaviors--drug use, sleeping late into the afternoon, social withdrawal, etc.--in an attempt to avoid the negative feelings. These behaviors provide temporary relief, but ultimately result in more negative outcomes, and worsening depression. When using behavioral activation, a clinician intervenes in two primary ways: They increase the amount of positive reinforcement a person experiences, and they end negative behavior patterns that cause depression to worsen. Replacing negative avoidant behaviors with new rewarding behaviors increases a person's positive reinforcement and reduces negative reinforcement.

5. What is the purpose of BA?
Increase environmental reinforcement
Reduce punishment
Decrease depressive symptoms
Decrease anxiety
Create “helpful disruptions” in cyclical thinking
Addresses automatic thoughts in the behavior changing process.
Behavioral activation was designed to increase one’s contact with positively rewarding activities.
In behavioral activation, you identify specific goals for the week and work toward meeting these goals.
These goals take the form of pleasurable activities that are consistent with the life the client want’s to live.

6. Introducing your Pt to BA
Orient to treatment rationale and approach
Develop initial treatment goals
Behavioral analyses (**think cause and effect**)
Repeated application of activation while promoting engagement strategies
Between you and the client (Modeling)
Between the client and others
Ongoing troubleshooting
Treatment review and relapse prevention
Educating Clients – close eyes give disclaimer about anxiety provoking (remember to breathe)
The goal of behavioral activation might seem simple (just replace negative behaviors with positive alternatives), but its implementation in real life comes with challenges. Imagine being in immense pain and having a tool that allows you to immediately relieve that pain. Now, imagine you have a tool that you hear will help more in the long run, but it isn't going to relieve the pain you're experiencing right now. Behavioral activation is the tool that will help in the long-run, but there won't be any instant relief. Unhealthy avoidant behaviors are the tools that provides instant relief, but ultimately do more harm than good. Because the goals of behavioral activation can be unclear to a client, education is an important first step. Clients who do not understand the reasoning behind behavioral activation are unlikely to be motivated to follow through. How is going out with friends or going for a walk going to help in the long-run when they still feel miserable doing these things? Why shouldn't they stay home in bed when that's the one thing that makes them feel better? It's the clinician's job to help a client recognize how their avoidant behavior (in this example, staying at home in bed) is causing their depression to worsen. This requires a clinician to listen, pinpoint negative behavior patterns, and collaborate with a client to figure out how they can be damaging. It can be helpful to draw a quick diagram, as shown below. 
Validating:
Interested; Accurately reflects; Genuine; Maintains hope and optimism about change
Reciprocal/responsive to client
Collaborative; Open to the client’s influence; Awake to client’s behavior in session and modifies interventions as appropriate; Warm
Non-judgmental and matter of fact in interactions with client
Everything is useful, provides information; Curious—holds a problem solving mindset in relation to all new behavior

7. Developing Positive Replacement Behaviors
After educating a client about behavioral activation :
Make a long list of positive replacements
Do this prior to starting your assessment and goal setting
Remember – create a foundation for success in the BA model.
This can't be emphasized enough: The positive replacements should be both easy and rewarding. Someone who is depressed might have a hard time getting out of bed by noon and brushing their teeth, let alone waking up at 6 AM, creating a résumé, or running a 10K. It can be helpful to create a list of positive rewarding behaviors, and rank them from 1 to 10 in the areas of ease and reward. Below are two worksheets to help with the process.

8. Strategies Involved in the Delivery of BA
Structuring strategies (including orienting to treatment)
Assessment strategies (individualizing primary treatment targets through behavioral assessment)
Activation strategies (activity structuring and scheduling)
Targeting avoidance, routine disruption, rumination

9. Assessment
Identify activity level within the patient’s natural environment
Discuss possible goals and select which ones to start with for homework.
(Remember: select the easiest goals first)
Define and specifically describe problems in behavioral terms (Ask exploratory questions)
Assess consequences of behavior
Examine behavioral patterns
Ask Basic questions:
What is maintaining the depression?
What is getting in the way of engaging and enjoying life?
What behaviors are good candidates for maximizing change?
Activity/mood monitoring provides the essential information
Utilize basic behavioral principles to answer these questions

10. Goal Setting Ultimate goal of treatment:
Clients modify their behavior to increase contact with sources of positive reinforcement
Typical goals relate to changing avoidance patterns and routine disruption and to changing environmental context
Focus on acting from the “outside in”
Set priorities for long and short-term goals
Figure out what behaviors are needed to reach goal—what, when, where, etc. Be focused, specific, and concrete!
Typical Questions to Guide Review
What would the client be doing if he or she were not depressed (e.g., working, managing family responsibilities, exercising, socializing, engaging in leisure activities, eating, sleeping, etc.)?
What is being avoided or from what is the client pulling away? How are these patterns related to mood?
What is the relationship between specific activities and mood?
What is the relationship between specific life contexts or problems and mood?
Is the client engaging in a wide variety of activities or have his or her activities become narrow?
Are there disruptions in normal routines?

11. Problem Solving Problem definition Generate and evaluate solutions
Practice new behaviors in session as appropriate
Skills training as appropriate
Troubleshooting
There is a cognitive element here.
It allows you to explore the behaviors and identify the underlying problems that are impacting one’s functioning.
While your focus will remain on the behavior, it will create opportunities for self-awareness and self-reflection.

12. Activity Scheduling Purpose: Typically uses a rating scale from 0-10
Increase pleasure
Increase involvement in daily activities
Increase approach (vs. avoidance)
Increase awareness of mood
Typically uses a rating scale from 0-10
Patients will document the number of activities per day (aim for 2 – 5)
**REFER TO HANDOUT
To assist with activity scheduling, therapists often assign an activity rating form on which patients maintain a record of their activities over the course of each day and provide ratings on a 0-10 scale for how much pleasure and mastery they experienced with each completed activity.
This is often useful data that can serve to counteract patients’ beliefs that they are unable to experience joy or gain a sense of accomplishment from any activities, and can help determine specific types of activities to assign in the future that are likely to lead to feelings of pleasure and mastery.
To assist with completion of assigned activities, patients may be asked to engage in imaginal rehearsal (sometimes termed cognitive rehearsal), in which they imagine themselves engaging in various activities in order to identify obstacles to experiencing a sense of pleasure or mastery from those events.[7] 
This enables the therapist and patient to then problem-solve obstacles and increase the chances of assigned activities leading to desired outcomes. 

13. Structure of Sessions Set collaborative agenda Review homework
Review weekly activities
Troubleshoot problem behaviors
Identify
Brainstorm
Resolve & plan for the future
Assign new homework
Ask for feedback

14. Maximize the activation:
Plan specific strategy for implementation (what, when, where, etc.)
Troubleshoot
Write it down
Monitor progress, highlight consequences
Adopt a scientific/experimental attitude
Be alert to the “just do it” approach
Take an “outside – in” approach
Break tasks into manageable components
Aim for activities that have a high likelihood of natural reinforcement
Consider help from significant others

15. Blocking Avoidance
Orient patient to avoidance (how it works in short run and long run)
Identify behaviors that function as avoidance
Help patient engage in alternative behaviors
Not getting resume done miss job opportunity
Not getting resume done ---- missed opportunity income is limited -----stress is elevated
Maybe ---- attend Michigan Works or Spark resume classes (problem solve to block avoidance in the future)

16. TRAP – This is what we don’t want
Trigger
Response
Avoidance-
Pattern

17. TRAC – This is what we want to achieve!!!
Trigger
Response
Alternative
Coping
T-Trigger (demands at work)
R- Response (depressed mood/hoplesness)
AC- Alternative Coping (approach behaviors using graded tasks)

18. ACTION Strategy Assess How will my behavior affect my depression?
Am I avoiding? What are my goals in this
situation?
Choose I know that activating myself will increase my
chances of improving my life situation and mood.
Therefore, if I choose not to self-activate, I am choosing
to take a break.
Try Try the behavior I have chosen.
Integrate Integrate any new activity into my daily routine.
Observe Observe the result. Do I feel better or worse?
Did this action allow me to take steps toward improving
my situation?
Now Now evaluate; OR Never give up.

19. Targeting Ruminating Attention to experience strategies
Identify physical responses
notice colors, smells, noises, sights, etc.
participate in new tasks
Select high engagement activities
What is ruminating?
“People with a ruminative response style think repetitively and passively about their negative emotions, focusing on their symptoms of distress ("I feel so lousy," "I just can't concentrate") and worrying about the meanings of their distress ("Will I ever get over this?“).”
Ruminative response styles predict higher levels of depressive symptoms over time, onset of new episodes, and episode chronicity
A Focus on the Content of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * What is the evidence that this thought is accurate? * What would it mean if it were true? * Can you think of another way to interpret what your sister said? * Why must everyone love you?
A Focus on the Context and Consequences of Thinking: “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” * When did you start thinking that? * How long did it last? * What were you doing while you were thinking that? * How engaged were you with the activity, context, etc.? * What were consequences of thinking about that?

20. Relapse Prevention Consolidate Treatment gains
What has been helpful?
What has been learned?
Plan for future problems
What targets have been identified
What new responses to targets are practiced

21. Challenges/Considerations
Clients may identify things that are unattainable/unrealistic.
Clients goals don’t offer enough direction to motivate behavior changes.
Clients share activities that they thinks other want them to focus on.
In doing behavioral activation, sometimes people identify activities that are important to other people. Basically, people identify activities based on what they think they should be doing as opposed to what they want to do.
If you come up with activities that are not important to you, it is going to be difficult to foster motivation and to really feel connected to the activities you are engaging in.
When identifying activities for behavioral activation, try to think of what is uniquely important to you. What matters to you?

22. References
Depression in Context (Martell, Addis, Jacobson, 2001), NY: WW Norton & Company, Inc.
Overcoming Depression One Step at a Time (Addis & Martell, 2004), Oakland, CA: New Harbinger, Inc.
Behavioral Activation for Depression: A Clinician’s Guide (Martell, Dimidjian, Herman-Dunn & Lewinsohn, 2010), NY: Guilford Press
BACKGROUND: Many depressed clients are withdrawn from activities, which previously provided a sense of pleasure or achievement. Inactivity contributes to low mood, which leads to negative thinking, and increased dysphoria and inactivity.  Automatic thoughts such as "this used to be more fun; I don't deserve to be doing this" lead to common reactions such as sadness, guilt, or anger at self. Therefore, depressed clients are likely to avoid the activity, compare their performance to when they did not have depression, or not engage in future repetitions of the activity.