Introduction

Behavioral Activation (BA) has a long history dating back to the late 1960s. During this history variants of BA have appeared, disappeared, and reappeared in new form. Currently two versions of BA are in widespread use (Lejuez, Hopko, & Hopko, 2001; Martell, Addis, & Jacobson, 2001) and these current versions have much in common with, and extend in significant ways, the earlier variants (Hopko, Lejuez, Ruggiero, & Eifert, 2003). Taking a historical perspective, it is clear that a number of techniques fall under the umbrella term BA, or the even larger umbrella term behavior therapy for depression (Kanter et al., 2010). A common technique across all variants of BA is the scheduling of specific activities for the client to complete between sessions. Thus, activity scheduling may be seen as the core of BA, and this core is strengthened by a variety of supplemental techniques. The skill of the BA therapist, as discussed later, is in determining what activities to assign, when in the course of therapy to assign them, maximizing the probability of successful completion of assigned activities, and determining when to use supplemental techniques.

Depending on training history, preferred theoretical orientation, and approach to psychotherapy, clinicians may have different reactions when it is suggested that they consider a behavioral model of disorder and treatment. Some may think behaviorism is cold, mechanical, superficial, and unable to foster the deep and meaningful psychotherapeutic relationships that many clients and therapists seek and feel are crucial to success (Skinner, 1974). In this chapter we aim to show that BA does not represent that kind of behaviorism, but that it is straightforward, sensible, and approachable, employing a rationale that clinicians and clients easily relate to and understand. The psychotherapeutic relationship in BA can be deep and meaningful, depending on the needs and desires of the client (and therapist). The techniques are easy to learn, are easy to implement, can be integrated without much disruption into ongoing work from other perspectives, and can be used cross-culturally with appropriate modifications and considerations. Most importantly, as Appendix B of this volume describes in detail, research indicates that BA, in terms of outcomes, is equivalent to, if not better than, other empirically supported psychotherapies and as effective as ongoing medication for the treatment of severe depression (Cuijpers, van Straten, & Warmerdam, 2007; Ekers, Richards, & Gilbody, 2008; Mazzucchelli, Kane, & Rees, 2009).

The empirical data in support of BA’s effectiveness, in combination with BA’s potential ease of dissemination and implementation, places BA at the cutting edge of an extremely important public health issue. Depression—the most burdensome disease in the world according to recent figures (Lopez, Mathers, Essati, Jamison, & Murray, 2006)—requires treatment strategies that are effective, easy to disseminate, and easy to implement for treatment to have maximum reach and impact at the public health level (Glasgow, Vogt, & Boles, 1999). With many individuals reporting reluctance to begin and maintain trials of antidepressant medications, and the majority of individuals reporting a preference for psychotherapy over medication for the treatment of depression, the development of effective psychotherapeutic strategies with BA’s qualities becomes important. We believe the data support BA’s use as a frontline treatment for a range of depressive presentations (mild to severe) and comorbidities. It also may be an effective adjunct to treatment of primary problems other than depression when depression is a part of the clinical presentation, or in any approach in which homework assignments are given to clients to change their behavior or engage in new behavior.

Theoretical Considerations

General Principles of Behavioral Activation

When conducting BA, several general principles are important to keep in mind (Table 4.1). At a basic level, these principles are foundational to any behavioral intervention, not just BA.

Table 4.1 General Principles of Behavioral Activation.

Behavior Is Best Understood Functionally, Not Formally

How do we define any behavior? In BA, it is useful to define behavior in terms of its function rather than its form. Consider a simple activity that would be typical of an activity assignment in BA: gardening. On a formal level (i.e., the form of the behavior), gardening involves pulling up weeds, watering the plants, and so forth. But this description tells us little about what is clinically relevant about this behavior. Clinically, rather than exactly what the person is doing, we usually want to know why the person is gardening (knowing what a target behavior is in detail is also important for developing good assignments, which will be discussed later). Is gardening a naturally positive reinforcing activity that the client used to do regularly before becoming depressed? Alternately, perhaps gardening is seen by the client as an unpleasant task, completed to escape continued complaining from one’s spouse? Alternately, perhaps the client is lost in thought while gardening, aimlessly pulling weeds but mostly ruminating about a recent fight with his mother? In the first case, gardening is a specific instance of contact with positive reinforcement. In the second case, gardening is a specific instance of negatively reinforced behavior (behavior that stops or avoids something aversive). In the third case, the client is not really gardening at all, and the behavior of interest is ruminating (also negative reinforcement).

Thinking about and describing behavior functionally requires an understanding of positive and negative reinforcement, as discussed earlier. The best way to improve one’s skill at thinking about and describing behavior functionally is to always ask about the potential future and achieved past consequences of the behavior. Questions include:

• How has the behavior affected others or the environment in the past? And currently?
  
• What is a behavior in the service of?
  
• What has the behavior produced in the past (i.e., positive reinforcement)? And currently?
  
• What has the behavior removed, stopped, or avoided in the past (i.e., negative reinforcement)? And currently?

A full-functional analysis of behavior would also include assessing the contexts in which specific behavior occurs. Later we discuss this more in-depth analysis, but the important point for now is that to understand a behavior’s function, the therapist should inquire about the consequences.

BA Is Best Accomplished Functionally, Not Formally

Although BA is a behavioral approach, the therapist does not need to sound like a behaviorist in the therapy room. Therapists do not need to describe the rationale with terms such as reinforcement or extinction. BA therapists use language that is functional, contextual, and pragmatic. We have encountered some behavior therapists who insist on using behavioral terminology with their colleagues and clients; while this may work with like-minded individuals, it may limit effective communication with others (especially those from other cultures). BA allows for the flexible, functional use of language rather than a dogmatic insistence on behavioral terminology.

Therapy also should be conducted functionally. Although this chapter and other manuals on BA provide the therapist specific instructions on what to do in session, these instructions also always should be applied with an eye toward what is working in the therapy room. Thus, we suggest a very specific structure for the therapy session (discussed later), but upholding that structure should not be the priority. The priority in BA always concerns the questions, Is the client getting active and is the client’s mood responding to that activity? However this happens is fine with BA as long as it happens. No specific form, structure, or technique is mandatory.

Thus, the best BA therapists are those who deeply understand the model and tailor it creatively to the unique presentations of their clients. For example, consider a depressed client who was already very active, spending long hours looking and applying for employment and scheduling lots of activities, such as going to the movies, with friends. The client also reported that she had lost several friends who “could not handle how depressed I am.” The therapist, a student trainee who had just learned the BA model, wanted to schedule some activities with the client in the first session (a good idea), and when the client reported what she was already doing, the therapist encouraged the client to keep doing those activities and planned out several of them in detail, including going to the movies with a friend.

Missing from this sequence of events was an attempt by the therapist to understand the behavior functionally. For example, when detailing a plan for going to the movies, the client reported that she used to like going to the movies by herself, but now if she does anything alone she is overwhelmed and is unable to do daily tasks alone (e.g., going to the grocery store). A goal for treatment could actually be spending more time alone. Thus, a better assignment would have been for the therapist to encourage the client to go to the movies by herself. Although in general most people prefer to see movies with friends, in this client’s case the avoidance of being alone had become problematic and pervasive.

BA Is Active, Concrete, and Focused on the Details of Clients’ Lives

We have heard over and over this common complaint from depressed clients about past therapists: “He was really nice, he listened to me and let me talk, but he rarely said anything and didn’t seem to have any ideas about what I should do differently.” A recent client compared work with the first author to a past therapist: “I would talk through most of the session, and then at the end she would encourage me to stay busy and fill my weekends with activities, but with you we spend most of our time on how to do that—you don’t just tell me I should do it and leave it up to me.”

Helping clients with how to successfully engage in life again requires being active, concrete, and focused on the details of clients’ lives. Consider the following interaction from Kanter and colleagues (2009, p. 105):

This interaction sounds like BA because it is focused on the client’s activity level and the clinician is emphasizing activation. Such an interaction would be typical at the beginning of therapy. However, there is much room for improvement in terms of a typical BA interaction. It could be less abstract, more concrete, more focused on the function of the client’s behavior, and more focused on exactly what the client can do differently. Consider an alternative to this interaction (modified from Kanter et al., 2009, p. 106):

In this alternative, the clinician immediately moves from an abstract discussion of the importance of activation to a concrete analysis of a specific instance in the client’s life. The clinician wants to understand this instance of behavior in enough detail such that specific, concrete recommendations can be made to help the client activate in that particular situation. We would then expect the client and clinician to continue this discussion, possibly for 5 or 10 minutes, until they have achieved a specific plan for what the client will do to get out of bed on specific days. Developing these plans is the heart of good BA. Without these detailed plans, one may suggest that the clinician is talking about BA but not doing BA.

BA Is Focused on the Present, Not the Past

It should be clear by now that BA is a present-focused intervention, and the mechanism of action of BA involves changing the client’s present behavior. That does not mean, however, that a BA therapist has no interest in the client’s past. In fact, understanding the past is important in helping the therapist understand the functions of the client’s current behavior, because these functions were determined in the past. It also can be recognized that some important functions may have been determined early in life (e.g., a history of abuse that has led to a pervasive pattern of fear and avoidance of genuine intimate relations with men); thus even discussions of early childhood can be appropriate in BA. In general, clients expect some discussion of their life histories, and therapists may devote some time to this, in the service of such general understanding, providing empathy and developing a good therapeutic relationship.

That said, insight into the past is not the mechanism of BA, and insight into the past without action in the present is useless from a BA perspective. Thus, the majority of a BA session should be focused on understanding a client’s current environment and current events in the client’s life, so action plans for how the client can behave differently can be developed. This is often pitched to the client as “I expect us to discuss the parts of your past that are directly affecting your current behavior.”

BA Is Focused on Behavioral, Not Cognitive, Change

In this chapter, we describe BA as a behavioral intervention, but sometimes it is loosely thought of as a cognitive-behavioral intervention as well. The terms cognitive, behavioral, and cognitive-behavioral have been used differently over the years. For example, Dobson and Dozois (2001), in Dobson’s (2001) well-used Handbook of Cognitive-Behavioral Therapies, suggest that all cognitive-behavioral therapies share three fundamental propositions: (1) cognitive activity affects behavior, (2) cognitive activity may be monitored and altered, and (3) desired behavior change may be affected through cognitive change. By this definition, BA is not a cognitive-behavioral therapy!

BA instead focuses on behavior change directly, without assuming that mediating cognitive variables need to change in order to change behavior. There is nothing in BA’s theory that states that behavior change cannot be achieved through cognitive change—it is just that cognitive change is not necessarily the only or the best way to achieve behavior change. In fact, several lines of research support the notion that cognitive change is not required for good outcomes in depression treatment (Longmore & Worrell, 2007).

In therapy, however, unless the therapist is in a research trial that requires the therapist to avoid implementing cognitive interventions such as restructuring techniques, there is no need for the therapist to dogmatically avoid any discussion of cognition. The primary issue is that cognitive restructuring interventions, in the context of a larger BA rationale that states that the goal is to get active regardless of negative thoughts and feelings, can potentially be confusing for clients. Thus, this chapter presents several ways that clinicians can respond to cognitive problems in ways that are consistent with the BA rationale.

Assessment in Behavioral Activation

The Therapy Relationship in Behavioral Activation

The Structure of Behavioral Activation

A BA session typically follows the standard session structure of cognitive-behavioral interventions (Beck, 1995) in which the client’s mood and symptoms are reviewed, an agenda is set, previous homework is reviewed, new homework is assigned, and the therapist asks for feedback or summarizes the session at the end (Table 4.2). Homework review and assignment are central to BA and allow the therapist and the client to discuss the details of the client’s life in the context of specific activation assignments.

Table 4.2 A Typical BA Session Structure.

As stated earlier, the session structure should not be applied dogmatically. As always, we recommend the clinician think functionally: For which clients will less structure be helpful, and for which clients will more structure be helpful? For example, some clients will resist the structure, and it will be in their interests to help them become more structured. This is particularly the case for clients whose lives outside of therapy are similarly unstructured and chaotic. For such a client, the clinician may provide a rationale for structuring the sessions:

I think the issue is that having a chaotic life is a risk for depression for you, because it makes it less likely that you’ll accomplish your goals for the day or the week. Part of what I have to suggest is a degree of structure that will be new for you. When people say “I don’t like structure,” it is usually because the structure is imposed by others—things people have to do that others want them to do or that they feel they should do. I want your days to feel less chaotic, more organized, more structured, but it will be a structure that YOU design (with my help), a structure that works for YOU, not one that I SAY you should do or that SOME BOOK says you should do, but one that you really feel captures what is important and meaningful to you. And a good place to start is to make sure that our sessions are structured, to make sure that we accomplish in here what is important and meaningful to you.

Therapy Structure

Variants of BA offer different guidelines on the degree to which therapy follows a structured course. BATD (Lejuez et al., 2001) offers a specific step-by-step protocol in which six units are delivered over 10 to 12 sessions. These units are: (1) introduction, (2) recognizing depression, (3) providing a rationale, (4) preparing for treatment, (5) getting started, and (6) charting progress, with the bulk of the work conducted in the last two units. BA by Martell and colleagues (Martell, Addis, & Jacobson, 2001; Dimidjian, Martell, Addis, & Herman-Dunn, 2008; Martell, Dimidjian, & Herman-Dunn, 2010) highlights the idiographic application of treatment strategies and only offers a general course that treatment may follow. This course is: (1) orienting to treatment, (2) developing treatment goals, (3) individualizing activation and engagement targets, (4) repeatedly applying and troubleshooting activation and engagement strategies, and (5) reviewing and consolidating treatment gains.

The structure obviously should be tailored to the needs of the client and settings of the therapist. In Figure 4.1 we suggest a course of therapy that is initially structured but becomes more flexible over time (Kanter et al., 2009). Specifically, Session 1 includes standard history taking and completing the intake interview, providing the BA rationale, beginning behavioral assessment, and provision of initial activation assignments. Sessions 2 through 4 continue behavioral assessment in order to create an activity hierarchy, which essentially functions like a case conceptualization in BA. During this time, additional activation assignments are given and reviewed. The initial hierarchy can be modified throughout therapy and guides activation assignments in subsequent sessions.

Figure 4.1 Course of Therapy

For many clients, these initial activation assignments will be successful and lead to a reduction in depressive symptoms. For these clients, no supplemental interventions will be required. For other clients, however, these initial activation attempts will not be successful and supplemental, more complex interventions will be required. This chapter provides a functional assessment (FA) strategy for the therapist to assess specific obstacles to successful activation. Supplemental interventions are linked to categories of obstacles identified by the FA, providing the BA therapist a simple guide to determine which supplemental strategies to employ for which client problems. This sequence, in which activity scheduling is employed in a fairly structured format, followed by additional techniques tailored to the specific needs of clients only for those for whom activity scheduling alone was not successful, may have several advantages and is an attempt to capitalize on BA’s existing strengths of parsimony, ease of implementation, and flexibility.

A particularly cost-effective way to deliver this version of BA is with a combined group and individual approach. In this approach, the therapist initially meets individually with each client to provide the rationale and to develop an initial list of activation targets. This is done in a single session. Then, the client joins a group that meets weekly to review activation assignments and schedule new assignments. This group has a rolling admission where clients may join and leave as appropriate. For clients who are doing well, they may stay in the group and help new clients with their assignments. For clients who are not responding, their group meetings may be supplemented by individual meetings with a therapist who performs the functional assessment and provides more complex interventions to help the client complete activation assignments. Although the current chapter focuses on an individual approach, the strategies may easily be modified for this group approach.

Providing a Rationale in Behavioral Activation

Next, the clinician may describe how depression is understood in BA with the “Two Circles Model” (Figure 4.2). This model depicts the basic relation between environment and behavior that is fundamental in general to behaviorism and specifically to BA. In this model, an arrow depicts how negative life events lead to common responses, which may lead to more negative life events, and this spiral results in clinical depression.

Figure 4.2 The General Two Circles Model

Circle 1: Negative Life Events

Clients may present in therapy with a variety of negative life events, problems, daily hassles, stressors, and the like. These negative life events can include:

• Divorce, marital stress, and dissatisfaction with or lack of intimate relationships.
  
• Difficulties with obtaining and maintaining employment with a livable wage.
  
• Health problems of all sorts including obesity, physical pain from injuries, and chronic health conditions such as diabetes.
  
• Daily hassles that are increased exponentially when living in poverty or lacking social support, such as use of public transportation, car maintenance, paying the bills, finding quality daycare if employed, and lack of insurance.
  
• Conflicts with friends or family members or lack of friends and family.
  
• Direct and indirect experiences of racism and racial, sexual, gender, or other forms of discrimination.
  
• Isolation from family and friends and loss of extended social support network and community if having recently moved to a new area.
  
• Experiences of trauma and violence.
  
• Disruptive “positive” events including pregnancy and childbirth.
  
• Other major losses, such as widowhood, death of loved ones.

The BA therapist determines collaboratively with the client the specific nature of the problems and stressors causing low mood. Some clients may report just one or two discrete problems or losses, such as death in the family, divorce, or recent unemployment. Others will report on the accrual of multiple smaller hassles and stressors. Others will have been living in chronically stressful and deprived environments for so long that they will at first have no losses to report on, because nothing new has happened or changed in quite some time. Regardless, undoubtedly there will be problems, and it is the job of the BA therapist to emphasize that many of the symptoms of depression make sense given these problems. The therapist should develop a list of these negative life events, write them down, and share them with the client. The therapist may call them “negative life events” and draw a circle around them.

Circle 2: Common Responses

It is a natural human response, when bad things happen (either major events, the accrual of smaller events, or the combination), to feel bad and to become passive. We call these common responses to emphasize that they are common and that the client is not weak, unusual, or crazy for having them. The important point for the BA therapist to stress is that these responses are common and make sense. Anyone would feel this way given the client’s situation. In this model, common responses include cognitive, emotional, and behavioral responses of the client including negative thoughts, lowered self-esteem, depressed mood, anger, irritability, avoidance, passivity, and giving up; in other words, the full psychological response of the client is relevant here. Some common emotional responses include:

• Sadness
  
• Feeling down
  
• Feeling blue
  
• Crying more
  
• Feeling depressed
  
• Experiencing less pleasure in things
  
• Grief reactions
  
• Fear
  
• Stress
  
• Physical symptoms
  
• Fatigue
  
• Anger, irritability
  
• Guilt
  
• Shame
  
• Despair
  
• Hopelessness

The client may also demonstrate a range of behavioral common responses to the negative life events, including the escape and avoidance behaviors discussed earlier:

• Passivity
  
• Avoidance
  
• Not wanting to go out any more (e.g., to church)
  
• Staying in bed
  
• Sleeping too much
  
• Calling in sick to work
  
• Withdrawing from friends/family
  
• Stopping housework
  
• Stopping looking for employment or only pretending to look for employment
  
• Drinking too much, smoking, using drugs, overusing prescription meds
  
• Filling every minute of the day to avoid facing problems
  
• Watching television for long periods of time
  
• Lashing out at others, including family and children
  
• Eating too much junk food
  
• Trying to kill oneself
  
• Acting like life is already over

It is the therapist’s task in BA to understand the client’s common responses to the negative life events, whatever they are, and to validate and normalize them. As this discussion is occurring, the therapist may develop a list of the client’s common responses, write them down, and label them common responses. The therapist may circle the list and draw an arrow from the negative life events to the common responses to show that they are an understandable response to the events.

Although emphasizing to the client that these responses are natural and normal and make sense given the negative life events, it is also emphasized that unfortunately these responses, especially the behavioral avoidance responses, tend to produce even more negative life events and create a spiral into depression. This is suggested by drawing an arrow back to the “negative life events” circle from the “common responses” circle. Clients almost always see this point readily and agree that their responses have just made things worse. Thus, the BA therapist compassionately explains to the client that treatment will help the client respond to life events proactively with activation rather than behavioral common responses. This is done by giving the client specific activation assignments based on his or her specific problems, and working closely with the client on designing activation assignments that will succeed.

Strengths of BA’s Rationales

We believe these simple rationales are a key strength of BA, because they are simple, easy to understand by clients, and easy to learn and apply by therapists. Research has suggested that these rationales also may be more helpful than traditional explanations of depression that emphasize biological factors in terms of reducing stigma about being depressed and receiving treatment for depression (Rusch, Kanter, & Brondino, 2009; Rusch, Kanter, Brondino, Weeks, & Bowe, 2010). The rationales also are relatively unencumbered by psychological constructs that may complicate adaptation and translation of the rationale for different cultures and languages; instead the BA rationales emphasize negative life events and empowering individuals to persevere in the face of difficult life circumstances, certainly globally accepted experiences and goals (e.g., Santiago-Rivera et al., 2008).

The rationales also do not require psychological sophistication and thus may be useful for clients without well-developed language skills for talking about feelings. For example, when reviewing common responses, some clients may not report any feelings in response to negative life events. For example, in response to the question, “How are you feeling in response to all this?” a recent client said, “I just can’t do anything anymore.” When the therapist probed again for emotional responses, the client again said, “I just feel like I haven’t been able to get anything done.” A therapist not practicing BA may see this sort of response as an indication that the client may need to become more aware of his feelings. In BA, however, the therapist may roll with this response and does not have to help the client understand or report on her feelings. In this case, the therapist may just focus on the client’s behavior.

Likewise, it is not important that the therapist educate the client about depression or the symptoms of depression. In fact, the therapist does not have to use the word depression while working with clients. Instead, the therapist should learn the clients’ language and descriptors of their problems, and fit the BA model to the clients’ language. The therapist should provide a good rationale for treatment that links the treatment techniques to whatever problems the client presents with. For example, a male client presented primarily with complaints of irritability and anger and said he was not depressed (although he met criteria for major depression according to an assessment interview). In such a case, the therapist may state that treatment will target those issues of irritability and anger. According to the “Two Circles” model, irritability and anger would be seen as common emotional responses to negative life events. Thus, treatment would involve activating alternate, more functional behaviors instead of anger expression.

It is possible that a client will emphasize physical rather than emotional symptoms, for example, feeling tired or in pain. This also is not a problem and the client does not need to be convinced to talk in emotional terms. The therapist may use the client’s language and terminology for how they are describing their experiences and use the somatic symptoms directly in the model. Usually these somatic symptoms can be seen as “common responses” and the therapist will want to focus on activating the client to maintain healthy lifestyles in the presence of these symptoms.

Dealing With Client Reactions to the Rationale

Some clients may misinterpret the rationale as “I just need to force myself to do things,” or “Just do it.” They may feel that they have already tried to get more active and have failed. In these cases, it is important for the therapist to emphasize his or her expertise in helping people change their behavior. The therapist may say:

The difference between what I have to offer you, and what you have already tried, is that I have lots of tips and tricks and ideas that help people make changes. People think it is easy to change their behavior, but if it was so easy you probably wouldn’t be here and you would have figured it out on your own. So we can look very closely at what behaviors we should change for you, how these behaviors should be broken down, and where we should start. Also, we can look very closely at how you and others respond when you do activate, and try to make sure that the right consequences are in place. It is not just about doing more things randomly; we are going to be very strategic about what you do and when you do it, and create a plan that over time will get you where you want to be.

Other clients may respond to the rationale by minimizing their own difficulties. A recent client seen by the first author stated, “I always think people are dealing with worse things…the death of a parent, abuse of a child…I always would just think I’d get over it, I don’t have things that tough…” In this case, the therapist responded:

The fact that worse things have not happened in your life is a good thing; I think that if more bad things had happened to you, you would be even more depressed and even more shut down, and it would be even harder to get you moving again. So we can together appreciate that others have things worse than you do, both because you would feel even worse and also because it would make our job harder. I think, given your life, your depression makes sense to me, you have had enough bad things happen, but at the same time certainly it could be worse…so I am optimistic that we can get you moving again.

It also may be helpful to emphasize that it is not the severity of the initial life events that matters, but how the client responds to those events—does the client respond with proactive problem solving or does the client respond in a way that perpetuates a spiral into deeper depression? It is important to not pathologize the client’s response here but to indicate that it is also a normal and understandable response—it just happens to be ineffective in this case.

A final client reaction to the rationale is to counter the behavioral rationale with a biological rationale: “I understand what you are saying, but my husband [or doctor, friend, etc.] says I have a biochemical imbalance.” A similar response to the behavioral model from other professionals such as some psychiatrists is to believe that the behavioral rationale is a good fit for “situational” depression but not real, clinical depression, which requires a pathological biological process rather than a process characterized by a normal response to life events (Horowitz & Wakefield, 2007).

Although certainly the clinician may enjoy a good debate with other professionals, it is important for the BA clinician to roll gently with these responses and not become argumentative with clients. The clinician may want to emphasize that behavior and biology are parallel, not competing, processes:

You are absolutely right. All behavior has a biological basis, so it is certainly the case that people’s brains change when they become depressed. However, there are many ways to change the brain, and therapy is one of them. So I am confident that, if there are any biochemical imbalances in your brain, we can actually work with them in here.

In fact, recent research has demonstrated significant changes in how the brain processes reward over the course of successful BA treatment (Dichter et al., 2009). It may be helpful to show clients this article, as it displays changes in fMRI images, and research has identified that these images are powerful communication tools.

Assessment: Obtaining Information to Guide Activity Scheduling

Here we review four sources of information (summarized in Table 4.3) to be used to assess these areas and build activation assignments. Like everything about BA, any one of these should be seen as optional, and the therapist should always be thinking functionally about obtaining this information in any way possible.

Table 4.3 Four Sources of Information to Guide Activity Scheduling.

Informal Clinical Interview

Important information can be obtained from the client simply by listening and asking the client informally about his or her life. This informal interviewing, which occurs mostly during the intake assessment, provides information useful to the conceptualization, particularly about things the client used to do and has stopped doing, and problems in the client’s life that need solving. Consider this Session 2 interaction with Bill:

As with much of BA, conducting a clinical interview of this sort should be fairly straightforward. The key, in fact, is for the therapist to remain fairly concrete, focused on the details of the activities that the client used to do and has decreased or stopped doing altogether, and what would be required to complete and reengage in the activities (e.g., a bike to go biking), without getting distracted by other possibilities that would complicate the conceptualization. Although the earlier example concerned the client’s hobbies, it is expected that the therapist will explore various life domains with the client as they complete their intake assessment. This intake assessment, covering family, social, educational, recreational, occupational, and other areas of functioning, should be a rich source of information for the therapist.

Activity Monitoring

The informal clinical interview described earlier is helpful in identifying what the client is not doing and problems to be solved, but activity monitoring is helpful in identifying what the client already is doing. The traditional tool used in early BA sessions to do this is the activity monitoring form, also called an activity chart. An initial monitoring assignment can occur in Session 1. The therapist may suggest:

Related posts:

Introduction: Evidence-Based Practice for Major Depressive Disorder One Size Does Not Fit All: Cultural Considerations in Evidence-Based Practice for Depression Cognitive Behavior Therapy for Depressed Adults Cognitive Behavioral Analysis System of Psychotherapy for Chronic Depression Cognitive Behavior Therapy Treatment for Adolescents Maternal Perinatal Psychopathology: Overview

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