How to Use Behavioral Activation to Help Your Clients Start the New Year
Nina Josefowitz, Ph.D., C.Psych.
The New Year is often a time when we assess our lives and think about our goals for the next year. It can be a time when we are particularly open to change. For example, we may think, “I am tired of being stressed all of the time, I want to really make some changes in my life,” or “I am always so depressed. I wish I could start the New Year differently.” Wanting to change is great, but as therapists, how do you build on this motivation in the therapy hour? Motivational Interviewing suggests listening for and reflecting any change talk. First, you want to reflect the “not wanting to change” part (for example, “I am depressed, tired and it’s so hard”) and then reflect the “desire to change” part (for example, “I hear you would like the New Year to be different” or “you would like to make some changes”).
Acknowledging the desire to change is important, but how do you help your client get going? I have found behavioural activation (BA) a helpful next step. While BA was developed to treat depression, many CBT clinicians also use BA with clients who have PTSD, anxiety disorders, are stressed out and overwhelmed or are disengaging from life for a variety of reasons.
Very simply BA is a set of tools that help us engage with life and face our problems. It is based on the assumption that depression is maintained by the vicious cycle of low mood leading to avoidance and rumination which then leads to increased low mood, which then leads to increased withdrawal and so on. Of course, adverse childhood events increase the risk of depression and psychological difficulties in later life and current stressful events can trigger depression and low mood. However, it is the vicious cycle of low mood/withdrawal that maintains depression. I often use the Figure below to show my client the vicious cycle of depression (Josefowitz & Swallow, 2024).
Introducing Behavioural Activation may sound like a good idea, but how do you begin? I start with the Daily Activities Schedule (DAS). For those new to CBT, the DAS is a worksheet that enables clients to track the relationship between their moods and their activities for a week (see Josefowitz & Swallow, 2024). When introducing BA, I usually say something similar to: “I hear you would like to make some changes in your life (linking it to the client’s goals), I have an idea that I think could be helpful in giving us a path forward (instilling help and linking the DAS to therapy). It is called a Daily Activities Schedule. It helps us understand if there are activities or periods of the day that are particularly hard for you and times when things are easier. It helps us understand the patterns in your life and their relationship to your mood. We then have a jumping off point to start making the changes you want.” Then, I get out a DAS, explain it to my client, and check if they have any questions. If clients don’t like having a paper worksheet, there are also many digital alternatives that can be found online. Collaborating with clients to help develop a tracking system that works well for them can be a way to increase engagement in the BA process.
I always complete the first day in session. This enables my client to immediately start exploring mood changes associated with different activities. My client then completes the rest of the DAS for homework. When examining the DAS with my client I try to use open questions that encourage my client to come up with their own conclusions while at the same time focusing on the mood/activity relationship. For example, I might say, “It seems that when you wake up you feel very depressed, but after breakfast you are a little bit better, what do you think?” and then “It would be important to know if this pattern continues throughout the week.” Another example might be “You had lunch with friends twice this week. How did this impact your mood?” Remember, conclusions your client reaches themselves will have more impact than anything you tell them.
Once your client has completed a DAS it’s time to start planning mood-boosting activities. In the beginning, I usually build on what the client is already doing. Later in therapy clients will add activities they used to enjoy or new activities that appeal to them. The data are clear that physical activity of any kind is a mood booster, especially if it can be done outside. Any kind of pleasant social activity is also a mood-booster, including contact with people in stores, colleagues, people you do activities with, close friends and people you are intimate with.
We also know that activities that are consistent with our values are a particularly strong mood-booster. Try thinking of an activity that you like. Then, ask yourself how this activity is linked to an important personal value. How did linking the activity to a personal value impact your motivation? For example, maybe you enjoy taking a walk outside. If you link walking to the value of physical health, you will give your motivation an extra charge. Many clients can easily link activities to values. If a client is having difficulty identifying their values, here are a number of suggestions: 1) you can find lists of values on the internet or in workbooks about depression (see below for some options). Clients can look over the list of values and circle the ones which mean the most to them. 2) Ask yourself who is someone you admire, and how come? The answer to the how come question will often help you identify your core values. 3) Imagine it is your 80th birthday. How would you like a good friend or family member to describe your life?
BA is highly effective, and many clients find it very helpful. However, sometimes despite your best efforts, your client comes to therapy and didn’t even try their mood-boosting plan, or they tried an activity, and it made no difference to their mood. What do you do next? Here are some suggestions.
Check that the plan has the characteristics of a successful plan. Effective plans are:
a. Developed collaboratively. In other words, it is not just your idea and the client nods in agreement.
b. Specific and concrete. What will your client do? When, where and for how long? Plus, what is the first step?
c. Doable for the client. This is important. Clients tend to want to do too much.
d. Part of a daily or weekly routine.
Demonstrate compassion towards your client’s difficulties. BA is really hard to do, especially when depressed. Model self-compassion, catch self-criticism, and look for change talk. Try to problem-solve what went wrong. Listen to your client’s difficulties.
Make sure you have identified the values associated with the plan and why it is important to your client.
Check how your client went about the planned activity. Did they take a walk while ruminating on all that is wrong in their life? Or, did they notice the colour of the flowers (Farb & Segal, 2024)?
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References:
Addis, M. E. and Martell, C.R. (2004). Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back. Oakland, CA: New Harbinger.
Centre for Clinical Interventions (2024). Back from the Bluez. Government of Western Australia. Can be retrieved from https://www.cci.health.wa.gov.au/resources/looking-after-yourself
Dimidjian, S., Herman-Dunn, R., & Martell, C.R. (2022). Behavioral activation: A clinician’s guide. New York: Guilford
Farb, N. & Segal, Z. (2024). Better in every sense. New York: Little, Brown Spark
Josefowitz, N. & Swallow, S. (2024). The behavioural activation workbook for depression. Oakland, CA: New Harbinger
