Module 11: Behavioral Activation

Objectives

• To understand the important clinical components and applications of behavioral activation strategies in
brief CBT.
• To learn skills and techniques to effectively use behavioral strategies for positive patient change
(especially related to increasing pleasant events)

What is behavioral activation, and why is it important?

Behavioral activation includes a set of procedures and techniques aimed at increasing patient activity and access
to reinforcing situations that improve mood and functioning. Behavioral activation amounts to the "B" in CBT
interventions. From this behavioral standpoint, depression, for example, contains a host of characteristics that
function to maintain depressive affect (e.g., passivity, fatigue, feelings of hopelessness) and decrease chances of
adaptive coping by increasing avoidance. The key here is that difficulty with mood often serves to increase
avoidance of adaptive coping, including pleasant events, which help to alleviate and avoid depression. Re-
introducing pleasant events (one form of behavioral activation) can serve to improve mood in many different ways
- 1) reversing avoidance, 2) increasing physical activity, 3) increasing self-confidence and 4) increasing feelings of
usefulness and purpose. Recent empirical evidence suggests that behavioral interventions improve mood
symptoms but also reduce maladaptive thought patterns (Jacobson et al., 1996).

An important point for therapists: Behavioral activation (alternatively referred to as increasing pleasant activities)
consists of a host of possible behaviors including, but not limited to,

1. Re-introducing prior pleasant activities

2. Introducing new pleasant activities

3. Active coping (e.g., taking some form of behavioral action) to alleviate or reduce a life stressor; examples
of active/behavioral coping that are not pleasant-event driven include

• Filing or getting taxes done

• Cleaning out a messy closet
• Calling an estranged family member

The goal of active coping is to decrease stress through accomplishment or overcoming avoidance.

When? (Indications/Contraindications)

Because of its relatively simple and straightforward approach, behavioral activation is a good technique for initial
stages of treatment and can be highly effective for patients with limited insight into their difficulties. Activation is
also easily measured (e.g., number, frequency, or duration of activities) and therefore can be used to document
and convey progress to patients (e.g., to increase treatment investment and improve patient self confidence and
control over symptoms).

Behavioral interventions are particularly powerful for depressed mood. Activation for depression generally serves
to get the patient moving. Almost all behaviors that include physical activity, planning, or accomplishing tasks are
appropriate here.

The use of behavioral activation for anxiety conditions requires a little more detail. Patients with anxiety symptoms
often avoid situations out of fear of negative consequence occurring in response to engaging in a particular
activity. Although behavioral activation can aid these patients, you must also understand that the activity itself is
not reinforcing (pleasant) but rather feared. It is only the resulting completion of the task that may generate
positive affect (e.g., I faced my fear, and nothing terrible happened). This response differs from depression in that
depressed patients will often look at behavioral activation as a positive outcome in and of itself (e.g., "exercising is
enjoyable" or "I love talking with my grand-daughter"). To effectively apply behavioral activation with anxious
patients, it is important to monitor anxiety and combine behavioral activation with relaxation techniques to

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increase patient comfort and control. Similarly, be careful not to allow behavioral activation procedures to further
aid in the patient’s avoidance of fearful situations (e.g., presenting problem is avoiding interpersonal difficulties
with spouse, and patient chooses to shop or be on the internet for pleasure but specifically when spouse is in the
house to avoid confrontation/talking about issues).

How? (Instructions/Handouts)

Step #1: Provide patient with rationale for behavioral activation.

It is important to educate the patient as to what behavioral activation is and how it can be useful for improving
depression and anxiety. Let him/her know that when feeling a little down or having a bad day and not feeling well
physically can make it more likely that he or she will stop doing many activities that used to be pleasurable. When
this happens, the patient can get into the habit of avoiding pleasant activities that might actually help him/her feel
better. It is also important for the patient to understand the connection between what he or she does and how
he/she feels, both mentally and physically. You are encouraged to explain to the patient that increasing activity
and/or taking action, even when we do not feel like it, help one to feel better physically, as well as decrease
depression.

Therapist: I would like to talk a little about what your day looked like yesterday. Walk me through
your day (e.g., what did you do in the morning, afternoon, evening)

Patient: Well, in the morning I woke up at 10 am and ate breakfast. I watched TV until noon. Then I ate
lunch. Around 2:30 I took a shower. At 3:00 I went for a walk with my dog.

Therapist: Okay, thanks. How did you feel in the morning?

Patient: Tired. I just couldn't get motivated and did not want to do anything. I guess I was feeling sorry for
myself – depressed, I guess.

Therapist: You say you were feeling depressed. If you had to rate that feeling on a scale of 0 to
100 (100 is worst depression) what would you say your depression was?

Patient: 65.

Therapist: What about in the afternoon after your shower and walk? How would you rate your
depression?

Patient: 20.

Therapist: To what do you attribute this change in your depression?

Patient: I guess I just got off my couch and started moving which helped me feel better.

Therapist: That would be my guess as well. (subsequently, explain the connections between
mood and behavior and encourage use of behavioral activation).

The figure below visually describes the connection between mood and behavior and can be an effective aid in
communicating with patients. To maximize the utility of the figure, you are encouraged to use the patient's own
examples. For example, you and the patient can work together to complete a daily activity log (see handout).
From this activity log, you might highlight activities that appeared to raise or lower the patient's mood.

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If depressed persons increase their activities on a daily basis, it improves mood and decreases symptoms of
depression.

Step #2: Identifying Behaviors - Discussing Activities.

Identification of potential activities begins by exploring with the patient activities that would be most meaningful.
Have a general discussion of types of things he/she would like to do but have not been able to do and activities
he/she already does but would like to do more often within the context of values or goals that are important to
him/her. You might want to ask if there is something that he or she needs to do that he/she has been unable to do
or has been avoiding. Some patients may want to accomplish something rather than focus on doing something
pleasant.

Possible questions might include:

• "Can you think of any activities or hobbies that you used to enjoy doing but have now stopped doing?"

• "Can you think of any activities or hobbies that you would like to do but have never done?

• "Are there things in your life that you would like to change? If so, what would you like to do about these
issues that you have previously not done?"

For patients who have difficulty identifying activities, you can introduce a behavioral activity checklist (see
Appendix).

Before completing the next steps (e.g., setting a plan), it is important to discuss the potential importance of the
behavior with the patient. If he/she reports low importance, encourage the patient to find another, more
meaningful activity.

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Step #3: Setting an Action Plan.

Once the patient has identified a meaningful activity to focus on, help shape this work into a meaningful
therapeutic goal. Action plans are one mechanism of creating meaningful behavioral goals for therapy. Action
plans in their most basic form stipulate the specific goal to be obtained, defined in terms of observable and
measurable characteristics and a timeframe for monitoring progress.

Example:

Goal: To read at least three times per week (a minimum of 30 minutes per
reading session).

Timeframe: Patient will complete three reading sessions over the next week.

An expanded action plan might also include:

a) Additional details of the plan – e.g., how the goal will be obtained

b) Possible barriers to reaching the goal and ways to address barriers if they arise

c) Possible facilitators of obtaining the goal, e.g., important people or situations that might aid the patient

d) Patient's confidence in reaching the goal in the timeline established; if confidence is low, you might
wish to alter the plan to increase chances of success.

e) Skills that the patient might want to enlist to help reach the goal (e.g., relaxation skills, problem-solving
skills, etc.)

Step #4: Monitor progress in mood, mastery, and confidence

It is important to monitor the patient's mood and feelings of mastery and confidence. Outcomes such as
improvement in mood, mastery, or confidence can be best identified through patient homework assignments that
ask the patient to document the frequency and use of the behavioral activity and any corresponding emotions or
feelings of mastery or confidence.

On the basis of this monitoring of outcomes, evaluate the action plan and the patient's ability to work towards
achieving goals. If problems arise, make changes accordingly (e.g., breaking down goals into smaller steps,
determining patient perceptions of importance and changing goals accordingly). Monitoring shows the patient that
you continue to believe in the importance of the technique/exercise and also serves to further motivate many
patients by increasing the effectiveness of the intervention.

Tips for Managing Barriers to Doing Activities

1) Help the patient break down more difficult activities into smaller steps. Look for alternative behaviors to
accomplish a goal prohibited by a chronic illness or other physical limitations. For example, a
structural/mechanical engineer who was forced to retire because of a physical limitation may feel that his/her life
is no longer productive. Although the patient is physically unable to fulfill prior job duties, you can work with
him/her to identify meaningful activities related to the prior occupation. In this case, the patient might benefit from
volunteering at a university, providing consultation (e.g., over email or telephone calls), or volunteering for a local
school, youth or church organization (e.g., talking about engineering).

2) It is also helpful and supportive to look for ways that others can help. Family or other social networks that the
patient has not yet fully engaged might exist, which might assist the patient in moving forward on goals.

3) Pleasant activities are the best first step. Pleasant activities are doubly beneficial to the patient, as they
increase activity and feelings of pleasure. Activities designed to overcome avoidance or increase a sense of
accomplishment should be entertained as the first goals only if highly important to the patient or apparently salient
to the attainment of future goals.

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 Summary of Steps

Step 1. Introduce behavioral activation and its potential influence to the patient.

Step 2. Use patient examples to show relationship between mood and behavior.

Step 3. Identify pleasant activities/active-coping behaviors.

Step 4. Set an action plan.

Step 5. Monitor progress.

Examples of Homework Assignments

1. What activities did you previously use to enjoy that you would like to start participating in again?
2. List activities that you need to do to better your current situation (enroll in school, get your inspection
sticker, etc.).
3. Create a schedule of the new activities you will perform. Which ones did you accomplish? Were there any
barriers? Why? How did you handle them?

Supplemental Readings:

Hopko, Lejuez, Ruggiero, et al. Contemporary behavioral activation treatments for depression:
procedures, principles, and prognosis. Clin Psychol Rev 2003; 23 (5): 699-717.

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 Mood Monitoring and Activity Chart

For each block of time, list the activity you did and rate (from 0-100) the level of Anxiety (A) and Depression (D) you experienced at that time.

Time Sunday Monday Tuesday Wednesday Thursday Friday Saturday

A: A: A: A: A: A: A:
6-7 AM
D: D: D: D: D: D: D:
A: A: A: A: A: A: A:
7-8 AM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
8-9 AM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
9-10 AM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
10-11 AM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
11-12 Noon
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
12-1 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
1-2 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
2-3 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
3-4 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
4-5 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
5-6 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
6-7 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
7-8 PM
D D: D: D: D: D: D:
A: A: A: A: A: A: A:
8-9 PM
D D: D: D: D: D: D:

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