Behavioral Activation Tip

Robert Hindman, PhD

Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.

 

To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.

 

It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).

 

The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.

 

Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.

 

References

Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.

 

 

Learn more about treating depression at the CBT for Depression and Suicide workshop.

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Teaching and Supervising CBT

donna_sudak-001by Donna Sudak, MD

 

Did you learn CBT through the tradition of “See one, do one, teach one?” Were your instructors and supervisors clinicians who had never learned the principles of adult learning? Did they instead teach or supervise you in the way they themselves had been taught or supervised?

Dissemination and training of quality CBT therapists has become a recent focus for CBT programs throughout the world. There is a renewed focus in the field of CBT and on the skills needed to effectively teach and supervise. In fact, CBT supervision skills have independently been recognized as a competency in recent years.

Perhaps surprisingly, little research exists on CBT training. What constitutes sufficient training? What does “competence” in CBT actually mean? How should therapist “drift” be monitored and assessed? Sudak et al (2015) summarizes the current research in training and supervision.

Training is defined as the effective transfer of knowledge about and practice of the key skills of CBT. It represents both knowing that and knowing how. Most skills are taught both in training and supervision.  Therapists or students first learn the rationale for a skill; they watch experts, and model what they have learned in practice with roleplayed “clients” of varying degrees of difficulty (with corrective and confirming feedback). Once trainees have the necessary skills, they can then be supervised with actual clients in a setting of “real world complexity.”

CBT supervision is most effective and efficient when the supervisor uses processes that parallel CBT therapy. The supervisory alliance is critical to effective work in supervision. The relationship needs to be safe enough for the supervisee to tell the truth and to be able to hear and incorporate constructive feedback. Supervisors should do a needs assessment with supervisees and then collaboratively set goals which form the “road-map” for supervision. Good supervision uses a session structure similar to that employed with clients in psychotherapy (Liese and Beck, 1997). By so doing, the model is reinforced and the supervisee can have an experience akin to self-practice.

Several other important parallels exist between effective supervision and therapy. These include using Socratic questions to stimulate learning and reflection, action plans between sessions and eliciting and giving feedback. Tapes of client sessions must be used to assess progress, rated by both the supervisee and supervisor with a validated instrument to determine fidelity and integrity, such as the Cognitive Therapy Rating Scale and client symptom rating scales provide data to determine if care is adequate and safe.

Supervision also requires conceptualization – both of the client and the supervisee. We are more effective supervisors if we develop a tailored educational plan based on the educational needs of the trainee and his or her capacities as therapist. The cultural competence and the cultural background of supervisees and clients should also be considered as a part of the conceptualization.

Supervisees should be encouraged to use thought records regarding their reactions to clients and expectations of themselves as therapists. This practice helps them to learn more effectively and inculcates the self-reflection that encourages expertise. Bennett-Levy (2003) has published extensively regarding this core process in CBT training. Active engagement and thoughtful implementation of several learning methods, as described by Milne and Dunkerley (2010), heightens curiosity and interest in supervisees.

Making our supervision and training more effective is also more engaging and fun for the teacher, so everyone benefits from this effort to improve our work.

 

Learn from Dr. Sudak at the Teaching and Supervising CBT Workshop.

 

References

Sudak, D.M., Codd, R.T., Ludgate, J., Reiser, R.J., Milne, D., Sokol, L., Fox, M. Teaching and Supervising Cognitive Behavioral Therapy. (2015) Hoboken: John Wiley and Sons.

Bennett-Levy, J. Lee., N., Travers, K., Pohlman, S., & Hammernick, (2003). Cognitive therapy from the inside: Enhancing therapist’s skills through practicing what we preach. Behavioural and Cognitive Psychotherapy, 31, 145–163.

Liese, B.S., & Beck, J. S. (1997). Cognitive therapy supervision. In E. Watkins (Ed.), Handbook of psychotherapy supervision. New York, NY: Wiley

Milne, D.L., & Dunkerley, C. (2010). Towards evidence-based clinical supervision: The development and evaluation of four CBT guidelines. Cognitive Behaviour Therapist, 3, 43–57.