Mag. Julia Weiss-Zamani
julia.weisszamani@gmail.com
What is the purpose of behavioral activation?
The behavioral therapy technique of activity building aims to increase the patient’s activity level. Above all, it is about performing more positively experienced activities and subsequently achieving pleasant feelings and an improved mood. Therefore, this technique is an important part of the overall therapeutic concept, especially in the therapy of depressed patients.
The theoretical starting point is the learning theory assumption of loss of reinforcer. It is assumed that depressive persons, due to their symptoms (lack of drive, social withdrawal, etc.), suffer a loss of positively experienced environmental reinforcement (sense of achievement, social contacts), which leads to a further deterioration of mood.
Through the activity building technique, work is done to help patients achieve a regular daily structure to a healthy extent, that is, to engage in neither too many nor too few activities and to find a balance, between pleasantly experienced activities and duties.
Indications and contraindications
Activity building is especially indicated when the person has low activity levels and avoids certain activities altogether. People with depressive symptoms in particular tend to be listless and to brood a lot instead of being active. Low activity levels may also account for a large part of the symptomatology as well as the maintaining conditions in chronic fatigue syndrome, as well as in psychotic residuals, somatoform disorders, chronic pain, panic disorders, and obesity.
It is important to ensure that the person is able to plan activities in a targeted manner (for example, is not acutely psychotic or demented), that the objectives set can be realistically implemented, and that the person does not feel overwhelmed, because a failure experience would be counterproductive. Furthermore, of course, no activities should be pursued that are contraindicated for other – for example, medical – reasons or would even contribute to the perpetuation of the symptomatology (e.g., excessive sports in anorexia nervosa).
Practical implementation of the activity setup
The activity building technique is usually part of a comprehensive treatment plan and is started as early as possible in therapy. Before they begin planning activities, it is important that the patient understands why activity building is important. This is because implementing increased activities can mean immense effort and overcoming for the patient, and thus it is inevitable that the patient is appropriately motivated. The patient is therefore provided in advance with a plausible explanatory model for the development of his symptomatology. In the case of depressive, listless symptoms, the therapist explains the “vicious circle of depression”, consisting of negative feelings, thoughts and listless behavior, which reinforce each other and thus lead to the “depression spiral” (downward spiral of depressive symptoms, in which all symptoms mutually reinforce or worsen). Individual, concrete examples from the patient’s own experience are worked out and discussed together with the patient. It is important to note that the activities should be built up slowly and gradually to avoid overwhelm.
In the concrete implementation of the activity construction, worksheets are used, such as a weekly schedule in combination with a mood log and/or an evaluation of the activity (pleasant – neutral – unpleasant).
Example of a weekly schedule (Monday-Sunday) with voting protocol (1-10):
The activity build-up is carried out in four phases:
Phase 1: Survey of the current activity level and elaboration of the functionality of avoidance.
After providing an explanatory model regarding the necessity and usefulness of activity building (depression spiral or way out of the depression spiral), the functional significance of avoiding activity is examined in the context of a problem analysis. What are the advantages and disadvantages of inactive behavior? What does inactivity “protect” the patient from or what does it avoid (e.g., feelings of failure, exertion, etc.)? The aim is to improve perception and self-reflection regarding listless behavior and its consequences.
As homework, the patient logs his current behavior using a weekly schedule. He is encouraged to enter his activities in the weekly schedule at least once a day and to record the mood existing at that time. In advance, it is discussed in detail how the weekly schedule is to be kept and which activities are to be entered. Especially in the observation phase, it is advisable to write down everything as precisely as possible in keywords, even those “activities” that are rather passive, such as “watching TV”, in order to gain an insight into the patient’s prevailing daily structure. Approximately one week is sufficient for this observation phase. In the following therapy session, it is discussed how satisfied the patient is with his observed daily structure and activity level. The frequency, intensity and duration of the activities performed are assessed (too much? too little? too short? too long? too excessive? etc.), as well as the quality of the activities performed (pleasant or unpleasant? easy to perform or only with great effort and overcoming? etc.).
Phase 2: Scheduling and carrying out increased activities, especially those that are experienced positively.
After analyzing the surveyed activities, objectives for change are discussed. Would more positive activities be useful or fewer duties performed and longer periods of rest and self-care? Are enough positive activities being done, but is too much of the duties left undone and becoming a burden? Are there too many listless “idle periods” on the couch in front of the TV that the patient could use for more active self-care, such as exercise, relaxation exercises, or self-esteem-boosting hobbies? Accordingly, specific activities are jointly selected and scheduled for the patient to complete by the next session. It is helpful to plan as precisely as possible in the weekly schedule. The patient should consider in advance when he or she would like to do which activity or can realistically do it. It is important to take into account the patient’s current symptomatology and to schedule only those activities that have a low level of difficulty so that, if possible, there are no experiences of failure. Initially, activities that are experienced as positive as possible should be scheduled so that the patient receives positive reinforcement. If the patient is unable to experience something as positive and pleasant due to depressive symptomatology, it may be helpful to revert to activities that were previously experienced as positive. It is important to build up gradually, so that not too many activities are planned at once, or those that would require too much effort from the patient (e.g. start with short walks instead of training for a marathon). Activities of short duration that can be carried out at regular intervals without much effort are preferable (e.g. “walking in the park for half an hour every day” instead of “going to the seaside”). Large projects should be broken down into sub-steps and planned as concretely as possible (e.g., schedule a time window of one hour to clean out a certain drawer instead of formulating the project “clean out the house”). For example, activities can be written in pencil on the weekly schedule and rewritten in pen as soon as they are completed. It is important to be able to identify what was planned for when and what of it was carried out. The selected activities should of course be formulated positively (e.g., “do a mindfulness exercise” instead of “don’t ruminate”) and be actively controlled by the patient himself, i.e., performed in such a way that he is as little dependent as possible on other people (e.g., “call friend Sabine” instead of “wait for Sabine to call”). The activities can be strengthened indirectly or directly. Activities that are experienced as pleasant per se involve immediate reinforcement. The amplifier quality should be explored carefully in advance. For example, something might have been classified as pleasant earlier but experienced as unpleasant in a depressive phase (e.g., “composing music” – but in the depressive phase the patient experiences himself as uncreative and gets under pressure). Unpleasantly experienced duties can be indirectly reinforced, for example by allowing the patient to think about and indulge in a reward for doing so.
Regular meetings are held to discuss how the patient is doing with planning and carrying out activities. It is discussed which activities the patient finds easy and which he tends to avoid and why. Those activities that the patient already performs regularly should be expanded. Those activities that the patient still avoids can be discussed in a problem analysis and, if necessary, prepared in more detail, e.g. practiced in a role play or similar.
Phase 3: Establishment of a daily structure and planning of specific activities
Once the general activity level is increased and drive is improved, it is possible to start building specific activities that the patient has been avoiding. These can be, for example, unpleasant or difficult activities that cost the patient a great deal of effort and still pose great challenges. It is important to discuss these activities in detail, to see what the patient needs to be able to do them. For example, does he still need competencies to work on building? For example, in the form of help such as joint preparation for an interview (working out formulations, role play, etc.) or working out partial steps that would make it easier to overcome (e.g. “design the first page of the application letter and then reward it with an episode from your favorite series” instead of “write applications”). When the therapist is sure that the patient can perform the action successfully, it should be included in the planning.
Phase 4: Maintaining the activity level
Once increased activity levels and also specific activities have been established, activities should still be logged and debriefed over several weeks. Difficulties that arise should be debriefed and worked on according to the approach in Phase 2 and Phase 3 (What is the problem? What does the patient need to implement and maintain the change?)
Success criteria, difficulties and mistakes
If the patient subjectively experiences that problems can be improved with active, goal-oriented behavior and that this has a positive influence on his or her own mood and drive, this is to be considered a success. By comparing activity logs, such as weekly schedules, objective success criteria can be collected (e.g., “last week I could only bring myself to go for a walk twice, this week already three times”).
The aim is to avoid setting the goals too high and planning steps that are too large and difficult. Furthermore, it is important that the patient understands why which activity is planned and that occurring (possible) difficulties are sufficiently reflected. It is also important to follow the patient’s individual pace and not to specify the individual partial steps too quickly or to increase the degree of difficulty too quickly. If possible, the patient should choose the activities they want to do and there should not be too many suggestions from the therapist. If the patient lacks his or her own ideas, a “list of pleasant activities” (e.g., Hautzinger, 2012), can be helpful. When difficulties arise, the therapist should not react angrily to them and should hold back on interpretations as to why this is so. Instead, it is more purposeful to use guided discovery to find out what the problem might be. Goals should be pre-formulated using a goal achievement scale that is as specific as possible and made verifiable (e.g., 3 times per week 1 hour of walking as a goal, but starting with smaller steps such as 3 times/week ½ hour of walking).
Activity building is considered the basic strategy of Cognitive Behavioral Therapy. Efficacy studies usually refer to the whole therapy rather than individual therapeutic techniques, but meta-analyses demonstrate the reduction of depressive symptomatology after increasing positive activities (Brakemeier et al., 2017).
Brakemeier, E. & Jacobi, F. (2017). Behavior therapy in practice (1st ed.). Weinheim:Beltz.
Linden, M. & Hautzinger, M. (2015). Behavior therapy manual (8th ed.). Heidelberg: Springer.
Hautzinger, M. (2012). Depressive disorders. In G. Meinlschmidt, S. Schneider & J. Margraf (Eds.), Textbook of behavior therapy. Materials for psychotherapy (Vol. 4, pp.313-322). Berlin: Springer.
