Behavioral-Activation-Group-Therapy-Client-Manual

Behavioral Activation Group Therapy Patient Workbook Name: _ Jeffrey F Porter, Ph.D and C Richard Spates, Ph.D Western Michigan University Kalamazoo, Michigan ∗ Introduction adapted from work of Jacobson et al (1996) Coping with Depression: A Manual for Self-Help The Problem Depression is a vicious circle When you first experience it, your body is telling you that something is not going well in your life Someone once described the experience as a bad case of the flu It slows you down, mentally and physically Everything becomes an effort, and you tire easily You less, and then blame yourself for doing less You come to believe that you can nothing, and that you will never get over your depression Then you feel even more depressed It becomes even more difficult to things And so it goes on It is important to recognize that your depression does not reflect some personal defect within you It is a signal that something needs to be done to change your life Either things have changed recently to make your life worse, or your life hasn’t been right for a long time, and your body has only begun to recently tell you The problem is that when people get depressed, instead of changing their lives in ways that are likely to improve their well being, they tend to blame themselves, withdraw from the world, and their lives get worse Gradually, they feel even more depressed Now they have two problems They still have lives that are not going well And now they have added a retreat from the world, which has made them even more depressed Overcoming the Problem There are a number of possible ways to overcome depression, and with your therapist, you will have the opportunity to use one of the most effective, which we call self-activation Activity breaks the cycle of depression But not just any activity With your therapists, you will first identify the two sets of problems that are contributing to your depression: those aspects of your life that need to be changed; and those actions you have taken to remove yourself further from the world, thus making you more depressed The activity is aimed specifically at positioning yourself to change your life and then actually changing it This guided activity is an excellent way to break the vicious cycle of depression It has a number of advantages: Guided activity makes you feel better It can give you a sense that you are taking control of your life again and achieving something worthwhile You may even find that there are activities that you highly enjoy, once you try them At the very least, becoming more active is an effective way to take your mind off your worries and your depressed feelings Initially, it places you in a state of readiness to make positive changes in your life Then, with the help of your therapists, your activity can be oriented directly toward making those life changes Guided activity makes you feel less tired Normally, when you are tired, you need rest When you are depressed, the opposite is usually true You actually need to more Doing nothing will only make you feel more lethargic and exhausted Doing nothing also leaves your mind unoccupied, so you are more likely to brood on difficulties and your lack of ambition, and to feel even more depressed Guided activity motivates you to more Many depressed people have the thought that if they only had the motivation, they would more and over come their depression What has been clearly learned, however, is that being active is the most effective way to increase motivation The more you do, the more you feel like doing Guided activity improves your ability to think Once you get started, problems, which you thought you could nothing about, come into perspective The unmanageable becomes manageable, and your mood will improve In spite of the advantages of getting more active, getting going again when you are depressed is not easy When you are depressed, you may think that you are doing nothing, achieving nothing, and enjoying nothing It may be difficult to organize your time productively, or to involve yourself in things you would normally enjoy Sometimes you can’t even imagine doing things that were once basic and easy The Group Your involvement in a therapy group offers unique and valuable experiences Instead of being limited to a single therapist, you will have two therapists working with you Instead of learning only from your own experiences, you will have the opportunity to learn from those experiences that other group members have, which may be very similar to your own Finally, you will benefit from assisting other group members in overcoming their depression as they the same for you As you can see, group therapy has few limitations As a group member, you will be expected to attend all group therapy sessions and to participate in every session This will involve a willingness to talk about your experiences and try new behaviors aimed at reducing your depression This will also involve a willingness to listen to other group member and offer suggestions to them on how to manage certain situations if you have had similar experiences You will benefit from both of these types of learning: Personal attention with a focus on changing your behavior and attention on others and how they manage different situations As you can see, a great amount of learning should take place even when you are not the focus of the group’s attention The treatment we will be using will help you with all of the problems in your life that inhibit your productive activity It will help you overcome those problems, and in that way get rid of your depression Working with your therapists, you will learn how to monitor your life, and how your actions affect your overall level of involvement in life You will learn what activities oriented toward improving the quality of your life might make you feel less depressed, either because they make you more productive or because they are simply enjoyable You will learn how to plan activities, how to monitor the effects of activities on your mood, and how to get the most benefit out of the things you You will learn about typical problems that people encounter when they try to change their activities, and how not to encounter problems yourself You and your therapists will work out a plan uniquely tailored to your situation, to optimize your daily activity schedule to make you less depressed You will learn how to get the most out of your day’s activities Above all, you will learn how to operate effectively in the world, and make the world a better place for you It may be easier than you think Lesson 1: Understanding Your Behavior To get less depressed, it is important to understand why we the things we Your behavior occurs for many reasons One reason that a behavior occurs is because something happens outside of you and you respond For example, a friend tells you that she cannot meet you for lunch and you cry Your behavior (crying) was a response to an event (your friend telling you that she cannot meet you for lunch) A second reason for your behavior is because of the positive consequence(s) that follows it For example, you eat a candy bar and you immediately get a good taste in your mouth Your behavior (eating) produced a desirable consequence (a pleasurable taste) When you something that produces pleasant results, you are more likely to that same thing again in the future Another way this works is when your behavior removes an unpleasant condition For example, your significant other is yelling at you on the phone and you hang up on him or her Your behavior (hanging up) removed an undesirable condition (being yelled at) When you something that removes an undesirable condition, you are more likely to that same thing again in the future To understand why a behavior occurs, follow these three steps: Identify the behavior Behavior is something that you In the first example crying was the behavior and in the second example eating was the behavior Ask yourself “What was the situation immediately before the behavior occurred?” In the first example it was a friend telling you she could not have lunch with you In the second example it was that you had no good taste in your mouth or you were hungry Ask yourself “What were the consequences of the behavior?” In the first example, the results of crying were probably that you felt a little relief or you got sympathy from your friend These consequences will make you more likely to cry in the future under similar circumstances In the second example, the results of eating were that you had a good taste in your mouth or that you were full These consequences will make you more likely to eat a candy bar in the future under similar circumstances Continued on next page… Example: It is Saturday evening and Jane is sitting at home feeling lonely She has no plans for the night so she decides to call her sister and invite her over to watch a movie Her sister accepts the invitation and Jane immediately feels better as a result of knowing that she has someone to spend the evening with What was the behavior? Jane calling her sister and inviting her to watch a movie What was the situation immediately before Jane called? Jane was lonely and feeling depressed What was the result of the making the call and inviting her sister to watch a movie? Jane’s spirits were lifted by her sister accepting the invitation and Jane knowing that she would not sit home alone all night So the next time you find yourself saying, “I don’t know why I this?” or “I don’t know why I did that” follow these steps to understand your behavior! Notes: Homework: Think of a situation recently in which you did something that you later thought “Why’d I that?” ♦ What was the behavior? _ ♦ What was happening immediately before the behavior? _ _ ♦ What were the consequences of your behavior? _ _ Lesson 2: Increasing Activities to Increase Feelings of Pleasure or Mastery When you are depressed, very few things seem enjoyable and you cannot seem to anything very well One of the ways to fight depression is to things that you enjoy or that you can successfully This can be accomplished three ways: Think about activities that were enjoyable or that gave you a good feeling before you became depressed What are the things that you used to like to do? It is likely that these things will be enjoyable again Example: Let’s say that before you became depressed, you used to enjoy working in your garden or on your car However, since you have become depressed, you haven’t done either because you don’t have the energy One way to start to reverse the depression cycle is for you to spend some time working in the garden or on your car When you this, it is important to remember that at first you will not be able to as much as you used to before you became depressed The important thing is that you are in there doing it again and eventually you will be able to as much as you once did Identify activities that have a high possibility of being successful It is important to plan for success, not failure At first this may mean doing simple activities by yourself Example: Make an agreement with your therapists that you are going to take a 15-minute walk every day for the next week Because you have a lot of control over this activity, you are likely to be successful at it Look at your list of activities that you enjoy or that you used to enjoy Start by doing one of those activities the first week and add a new one each week so that by the end of therapy you are doing many of the activities you enjoy Example: You have a list of 20 activities that you have enjoyed at some time From the list, you decide to read one chapter in a book during the first week During the second week you read another chapter and go to the hardware store, even if it is just to look around The third week you read a chapter from the book, go to the hardware store and call a friend and talk on the phone and so on and so on Continued on next page… Notes: Homework: Step 1: Make a list of activities that you enjoy or used to enjoy Step 2: Rank them from the most likely to at this time to the least likely to at this time Step 3: Decide which or of the ‘most likely to at this time’ activities you are going to add to your life in the next week Do this each week If you run out of activities, add to the list Lesson 3: Understanding Self-defeating Behavior None of us are perfect and despite our desires, we still things to make our own situation worse By knowing what you are doing to make your depression worse, you will know what to avoid doing Self-defeating behaviors are those things you that, in the end, make your depression worse You can tell if a behavior is self-defeating if there are positive consequences at first but negative consequences later on Unfortunately, it is usually the immediate consequences that control our behavior, which is why we things that are bad for us If the delayed consequence of your behavior is that you feel worse, then it is probably a self-defeating behavior To identify self-defeating behavior, ask yourself the following questions: What are my problem behaviors? ♦ What am I doing more now than I used to before I was depressed? ♦ What my friends and family tell me I too much of? ♦ What I to cut myself off from the world? What is happening before I this thing? What are the results of acting this way (both immediate and long-term)? Example: Since John has become depressed, he avoids people and spends most of his free time by himself John used to be very social and so this is a big change for him John wonders if this is a self-defeating behavior So John asks himself what it is that might be self-defeating He decides the behavior is avoiding people He asks himself what is happening before he avoids someone He sees that he feels nervous about talking to others because he feels so depressed and believes that he has nothing to say He then asks himself what the results are of his avoiding people He realizes that in the short-run, avoiding people allows him to avoid some uncomfortable anxiety (a positive result of the behavior) However, he also realizes that in the long run he feels cut-off from the world and extremely lonely (a negative result of the behavior) Thus, John decides that avoiding people is a self-defeating behavior Continued on next page… 10 NOTES: Homework: Identify two self-defeating behaviors 1) Define the behavior—What are you doing? _ 2) What is happening or what are you feeling before you this? _ _ 3) What are the immediate results of doing this? _ What are the delayed or long-term results of doing this? _ 1) Define the behavior—What are you doing? _ 2) What is happening or what are you feeling before you this? _ _ 3) What are the immediate results of doing this? _ What are the delayed or long-term results of doing this? _ 11 Lesson 4: Active Rather Than Passive Behavior When you are depressed, you are more likely to let things happen than to make things happen The result is that you feel like you have very little control over your life and that nothing you makes a difference Consequently, a goal of treatment is to make you more active in your own life In other words, you are going to be a participant in your life rather than a spectator of your life • Being active means doing things that cause you to feel good • Being active means doing things that cause an unpleasant situation to get better Examples: ♦ Calling an old friend is active if that experience makes you feel better, even temporarily ♦ Talking to your spouse when he is angry with you is active if that helps resolve the unpleasant situation • Being passive means failing to things that make you feel good • Being passive means failing to things to make an unpleasant situation better Example: ♦ Sitting around the house waiting for someone to call is passive because you not feel better unless someone else does something active ♦ Allowing coworkers to tell you how to your job without expressing your thoughts is passive because it fails to resolve an unpleasant condition NOTES: Continued on next page… 12 Homework: Identify a few of your active and passive behaviors Active behaviors: Describe what you did and the positive consequences of doing it 1) 2) 3) Passive behaviors: Describe what you did (or didn’t do) and the negative consequences of doing it 1) 2) 3) 13 Lesson 5: Increasing the Difficulty of Tasks When you are depressed, tasks that were once doable and even easy can seem impossible As a result, you feel like you never get anything done When this happens, the first thing to tell yourself is that this is a result of the depression and not of your inability to be successful It is quite simple: you cannot depressed what you can non-depressed One strategy to use in this situation is to break a task down into small parts Once you have identified these parts or steps, decide that you are going to start tackling the task one step at a time Once you have completed one step, move on to another Once you have completed that step, move on to another and so on and so on Example: Since Sue became depressed, she has been unable to clean the house The house used to be spotless but now she’s lucky if one room gets cleaned Therefore Sue decides to break the cleaning into many parts and tackle them one at a time There are five rooms in the house and each one needs to be picked-up, vacuumed and dusted Sue decides that on the first day, she is going to vacuum two rooms and that is all If she can get that accomplished, she has been successful She finds that she was able to it and it was easier than she thought She decides that on the second day she is going to vacuum the other three rooms and dust the living room She is able to that and now she has the whole house vacuumed and one room dusted She decides that on the third day she will dust the other four rooms and she is able to this and so on and so on As these tasks become easier for Sue as her depression lifts, she is able to more and more at one time until after several weeks she is able to clean half of the house at one time NOTES: Continued on next page… 14 Homework: Step 1: Identify a task that you have been unable to accomplish recently Step 2: Break this task down into its smallest parts and list each of them 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Step 3: List the steps in order that you are going to them Cross a step off as soon as you complete it Go it! 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 15 Lesson 6: Mental Rehearsal of Activities When you are depressed you are kind of like a big boulder; you’re stuck in one place and getting you moving is the hardest part For you, getting you moving means doing things One part of depression that can really make doing things difficult is anxiety Anxiety is the nervousness you feel because you don’t know what the outcome of doing something will be One way to fight this anxiety is to imagine yourself doing the activity before you actually it You can this by visualizing yourself doing the activity and talking your way through it This can help you predict what obstacles might get in your way and think of ways to get around them if they occur Example: Mike has agreed to call a certain friend who he has not talked to in two months because of his depression This is a big step for Mike and the thought of making the call makes him pretty nervous Therefore, Mike rehearses the phone call with the help of his therapist Mike says “I pick up the phone and start to dial the number.” Mike’s therapist asks him what would happen if he gets nervous and hangs-up before he finishes dialing Mike says “I will take a deep breath and remember that I agreed to this and just it.” Mike then says “Paul answers and we begin to talk and I ask him if he wants to something sometime.” Mike’s therapist helps Mike imagine Paul’s different responses and rehearses how to deal with them Mike and his therapist this until Mike feels comfortable that he will be able to make the call NOTES: Homework: ♦ Identify an activity or situation that has been difficult for you Close your eyes and imagine yourself doing it ♦ What could go wrong? How would you handle this problem? Imagine yourself adjusting to this problem ♦ Which parts seem easy for you? How can these help you through the difficult parts? Imagine yourself successfully completing the activity 16 Lesson 7: Examining Other Behaviors When you are depressed, it is difficult to see options You tend to see yourself and the world as negative and you get stuck in a rut that makes you feel miserable One way to get “unstuck” is to get someone’s help coming up with different ways of acting in certain situations Example: Mary is very bothered by a fight that she had with her husband two days ago She says that they fight all of the time and that the same thing always happens She gets so angry with her husband that she begins yelling and calling him names until he finally leaves Mary hates when this happens but doesn’t know what to With the help of her therapist, Mary makes a list of things that she could have done differently in this last fight For example, she might have walked away until she had cooled down Or she might have stood there and said nothing Or she might have hit and kicked her husband The point is, there are several things that she could have done differently, some better and some worse By making a list of other things to do, she will be able to try some of these things in the future when they have a fight NOTES: Homework: Identify a recent problem that you believe you handled poorly ♦ Generate a list of ideas for other ways of handling this problem: 1) 2) 3) 4) 5) 6) ♦ Now but a “B” by the idea if it is a better way of handling the problem or a “W” by the idea if it is a worse way of handling the problem ♦ Make a commitment to try one of your better ideas the next time 17 Lesson 8: Practicing Behaviors with Group Members When you are trying out new behaviors, it is usually helpful to practice the behaviors before you use them in a real life situation Being part of a group gives you the opportunity to practice with others in the group Example: Susan has been having a lot of trouble managing her kids lately She does not seem to be able to talk to them without getting angry Therefore, Susan learns some new ways to talk to her kids and new ways to deal with her anger But before using these new skills with her kids, she wants to practice them So during the group, several group members pretend to be her kids and they create situations that are similar to those that occur at home Susan practices using her new skills and the group members acting as her kids respond in ways that Susan’s kids are likely to respond NOTES: Homework: ♦ Identify a new behavior that would be easier to if you could practice it first _ ♦ How many people would it take to practice? _ ♦ Who would the people pretend to be? _ 18 Lesson 9: Ensuring Homework Success A big part of this treatment is to perform homework assignments between therapy sessions The purpose of these assignments it to activate yourself in a way that relieves your depression Therefore, it is extremely important that you assign yourself homework that you can successfully Failing at a homework assignment is only likely to make you feel worse When you are deciding on a homework assignment, ask yourself the following types of questions: ♦ “What could get in the way of me completing the homework?” ♦ “Is there a specific time for the homework that will make it easier?” ♦ “Is this assignment doable by me today, given my level of depression?” Example: Sherry’s homework is to exercise every morning for one hour However, mornings are very busy for her because she has to take care of her children and get them off to school Therefore, there is a good chance that she will not be able to complete this assignment due to her busy morning schedule Because Sherry wants to be successful with her homework, she asks for help on how to schedule it After talking about her usual schedule, it seems that from 1:00 to 2:00 she is free and she decides that this will be her exercise time each day NOTES: Homework: ♦ Identify a homework assignment that has been difficult for you or that you have not accomplished: _ ♦ What has gotten in the way of doing this? ♦ What changes in the homework would increase your chances of successfully completing the homework? _ 19 Lesson 10: Distraction from Problems When you are depressed, you have a tendency to get “stuck” thinking about problems and negative things in your life While it is certainly not good to avoid problems altogether, it also is not good to dwell on them to the point that you feel terrible Therefore, with the help of your therapists, you will learn new ways to behave when you find yourself “stuck” on a problem Your therapists will help you find things to that will get you “unstuck” and allow you to focus on healthier parts of your life Example: Jack reports that he sat around all weekend thinking about the problems his daughter was having in school Even though he was doing everything he could to help her, he continued to worry about her and could not seem to stop thinking about her problems Jack’s therapists suggested some activities that would help take Jack’s mind off of his daughter’s problems They suggested that Jack call a friend and talk for a while, or read a book, both of which are activities that Jack enjoys NOTES: Homework: ♦ Identify a worry of yours that won’t go away: _ ♦ Generate a list of activities that you could that might take your mind of off the worry: ♦ Make a commitment to try at least of them the next time you cannot stop worrying 20 Lesson 11: Avoiding Unpleasant Situations or People When you are depressed, you may have the tendency to allow yourself to get into situations in which you end up getting hurt For example, your brother may be very critical of you and say things to hurt you, yet you still talk to him by phone or visit him The remedy to this problem is active behavior; avoid putting yourself in situations that you know will make you feel worse Example: Tom reports that every time he visits his mother she tells him how he is wasting his life being a bricklayer Yet Tom continues to see his mother regularly and therefore sets himself up to be hurt He does not think confronting his mom about her hurtful comments will help him So Tom’s therapists suggest that he avoid seeing his mother for a while or only see her when she is least likely to make such hurtful comments, like when other family members are present NOTES: Homework: ♦ Identify a situation that you find yourself in repeatedly and the outcome is always the same: you get hurt _ ♦ What can you change about the situation or your behavior so that you not get hurt? _ 21 Lesson 12: Improving Your Skills Often times when you are depressed, learning a new skill helps to get you “unstuck” and moving in the right direction Your therapist can help you to learn new skills that will help you fight your depression Here’s how you it: With the help of your therapists and other group members, identify a skill that you need to improve on You can this by asking others in the group for suggestions Once you have identified a skill, ask the therapists to show you how to it better Now practice these skills with the group members The therapists are there to make suggestions and help you improve Example: Betsy is having difficulty communicating with her spouse and fights between them are common She asks the group members how she communicates and they all agree that she yells too much She then asks the therapists to teach her how to be angry and talk without yelling The therapists model some communication skills in a pretend argument with each other Betsy then practices using these skills with other group members and the therapists help her NOTES: Homework: ♦ Identify a skill that you lack or that you not feel competent at: ♦ Ask for help and practice it with the group 22 Lesson 13: Giving Yourself Rewards for Good Behavior When you are depressed, you are likely to notice all of the bad things you but you probably don’t give yourself any credit for the good things you And the truth is, not many other people notice the good things we either So you need to become your own fan and cheer yourself on when you something well This means that you have to learn to reward yourself for your accomplishments Even the ones that seem little, like making dinner or doing the dishes How to this: Define a task so that you can tell for sure whether or not you completed it For example, ‘cleaning the house’ is not a very good definition of a task because something else could always be done to make it cleaner and when you are depressed, you will take every chance you get to find the failure in yourself A better definition is ‘vacuuming the bedrooms’ or ‘washing and drying the dishes and putting them away’ If you have done these, you will know it and you cannot talk yourself out of the accomplishment The second step is to reward yourself with something after you have completed a task This might be 30 minutes of TV or a bowl of ice cream or a hot bath The point is, you are rewarding yourself for a job well done Example: Molly complains that she is unable to start a project at home that she has wanted to for a long time The therapist suggests that Molly break the project down into smaller, easier steps After she completes each step, she rewards herself by buying herself a new tool NOTES: Continued on next page… 23 Homework: ♦ Clearly define a task that that has been difficult for you and that, upon completion, you would be deserving of some reward: _ ♦ List some rewards for yourself that you would enjoy and that would be possible:  Activities (taking a bath, watching a movie, going to the mall)  Goods (article of clothing, a favorite food, something for the house) 24