Behavioural Activation – self reflection on a CBT intervention

When learning to carry out therapeutic interventions or treatments, it’s important to understand the mechanisms of the task in detail, and what better way to get to the bottom of that than by using the technique on yourself? Here I practiced a standard CBT intervention for depression, Behavioural Activation, and reflected so that in the future I can improve the experience for clients in the future.

What is the background to the intervention you practiced?

I practiced Behavioural Activation, which has its foundations in cognitive behavioural therapy. Cognitive Behavioural Therapy posits that our thoughts and behaviours can affect how we feel emotionally and physically, and that by modifying our behaviour and cognitions, we can help improve our physical and emotional wellbeing (Beck, 1979). Behavioural Activation focuses on the behavioural aspect of this cycle and suggests that when people are feeling low or depressed, they may stop doing things that give them the opportunity for pleasure or a sense of achievement (Richards & Whyte, 2011). The intervention itself encourages individuals to schedule pleasurable, routine and necessary activities in a diary, which they then carry out and which positively reinforces this behaviour and thus lifts their mood (Dimidjian et al, 2011). There is a large evidence base for this intervention; in particular, a meta- analysis of 780 participants, found it to be an effective treatment of depressions with a large effect size (Cuijpers et al, 2007).

What did you find easy?

I found the broad process of identifying activities, then categorising them and putting them in order, and then scheduling them throughout the week quite straight-forward to follow. I also found the templates easy to understand and fill out. The rationale also made sense to me too. The template encouraged me to think about the ‘what, where, who, when’ of the activity too which I found useful because it made me think through things like ‘what time would work best?’, ‘if someone else is involved do I need to talk to them and if so, when?’ or ‘is home the best place to this?’, so in this way it encouraged me to plan carefully, and at points, break the task down into separate steps.

What did you find difficult?

I found a lot of the exercise difficult, perhaps because I tend to be quite a busy person, who doesn’t tend to avoid things and isn’t depressed!

Initially I found it hard to find things to fit in every category of routine, necessary and pleasurable so I had to be quite creative, and then putting them into order of easiest to most difficult felt somewhat arbitrary because none seemed particularly difficult, although I’m aware that for someone who was depressed this may well be more straight forward.

I then found that as the format of the activity scheduling diary we were using only allowed for morning, afternoon and evening slots, it didn’t allow for enough detail to fit all of the things that I wanted to do, so I ended up using a service-provided diary with hour by hour slots to help me plan the activities more successfully.

Another challenge for me was remembering to use it. I had printed it out, but keeping it with me as a reminder at all times was hard, so I found myself having to find it again, check it again on multiple occasions, which was annoying. It’s also quite a private document to have lying around, and so it felt uncomfortable knowing that someone else might happen across it and maybe judge me on the variety of activities I’d put in the planner. It made me feel quite vulnerable!

What parts were a learning experience for you and how will this guide future practice?

I learnt a lot about the challenges of doing the intervention and as such I would work with patients differently.

I learnt that the materials need to suit the individual’s lifestyle and as such I would offer patients multiple formats of the diary and I would also discuss how they might like to complete it in a format which they already use such as their own diary or phone, in which case they could also schedule reminders to help them remember tasks.

I learnt that some activities may need other people’s support but that others were quite private and as such I would also discuss with clients the fact that they may want to share their plans with their family to get support with carrying out their plan, or, if they feel uncomfortable doing this, that they may want to consider somewhere in advance, that they could keep their plan securely, so that they feel safe in the knowledge that they won’t be judged on their activities.

I learnt that plans need to be flexible to allow for life’s surprises so I would also discuss the need for flexibility in their use of the diaries, and the fact that if they can’t do one task at the scheduled time (for whatever reason) then the patient can of course change the time and date, or indeed substitute the activity with something else from their list.

I also found at the task is harder than I had imagined, so I would also normalise the fact that this can be a difficult task, as I feel that this would help them a manage their expectations so as to minimise the risk that they become disheartened at an early stage.

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