In this chapter, you will find an account of:
rThe use of common behavioural techniques in cognitive therapy for depression
rThe benefits to be sought from using these techniques in persistent depression
rCommon problems encountered in helping patients to monitor their activities
rCommon problems encountered in helping patients to schedule satisfying activities
rSuggested ways to progress in therapy when each kind of difficulty is encountered
Helping patients to regain some satisfaction from activities in their lives is an important aim of cognitive therapy for depression. Cognitive therapy for acute depression (Beck et al., 1979) incorporates a range of behavioural techniques that are used to help patients to re-engage in satisfying acti-vities. Many of these were adapted from more exclusively behavioural approaches to depression (e.g. Lewinsohn, 1974). Behavioural techniques such as monitoring activities, scheduling activities and graded assignment of tasks have come to be seen as standard approaches in cognitive therapy for depression. As we have described, the presentation of patients with persistent depression can be markedly different from that of patients with more acute depression. The implementation of behavioural techniques therefore needs to be adapted to take account of these differences. In this chapter, we review some of the standard behavioural techniques used in cognitive therapy for depression and the rationale underlying their use.
We then consider each of the main standard techniques and identify some of the most common problems that are encountered when trying to use them with persistently depressed patients. In each case, we suggest ways of maintaining some benefit from the use of these strategies.
Many of the difficulties in trying to implement behavioural techniques in chronic depression reflect the influence of the chronic cognitive triad of low self-esteem, helplessness and hopelessness. This triad in turn arises from rigid underlying beliefs and longstanding patterns of avoidance.
Behavioural changes may thus be extremely hard to institute in therapy.
Even when patients do manage to change their behaviour in ways that may be thought to be beneficial, the degree of symptom relief obtained may be limited. Therefore, as well as aiming for symptom reduction, the use of behavioural techniques in chronic depression is undertaken with broader aims. These include helping patients to recognise when and how they are avoiding things, to assess the effects of avoiding and grad-ually to consider the possibility of engaging with avoided activities or issues.
STANDARD BEHAVIOURAL TECHNIQUES IN DEPRESSION
Rationale for the Use of Behavioural Techniques
Many acutely depressed patients spend significant stretches of time doing little other than sitting thinking about their problems. Inactivity and reduced levels of motivation in acute depression are important targets for cognitive therapy. In the cognitive model of depression (see Chapter 1), reduced levels of activity are assumed to exist in a vicious circle with low mood and negative biases in the patient’s thinking. When the patient’s mood is low, their thinking about any endeavour becomes dominated by negative expectations, and they are put off from engaging in activ-ities that were previously satisfying. As the patient ceases to do things that they previously found rewarding, the reduction in levels of satisfac-tion or positive reinforcement directly contributes to low mood. More-over, reductions in activity can then provide fodder for more negative thinking: as patients reflect on how little they are doing, they criticise themselves for their ‘laziness’ or worry about their apparent incapacity.
The negative thoughts triggered by inactivity can then result in a fur-ther lowering of mood and motivation, which limits activity levels still further.
Once a patient has been socialised into the cognitive model, the next stage of cognitive therapy usually involves helping the patient to re-engage in activities in order directly to increase levels of satisfaction. Re-establishing previously rewarding activities can also highlight negative expectations that can then be put to the test. By using the active, questioning style of
cognitive therapy (see Chapter 2), the therapist aims to engage the patient in collaboratively identifying activities that might improve the patient’s mood. A number of techniques can be used in pursuing this strategy, the most common of which are monitoring of activities, activity scheduling and graded task assignment.
Monitoring Activities
Initially, patients monitor their levels of activity and concomitant satisfac-tion. They may be asked to record their activities over the course of the day on an hour-by-hour basis, and to rate the degree of mastery (i.e. sense of accomplishment) and pleasure obtained from attempting each activity.
Monitoring activities in this fashion often provides a number of benefits in depression. Frequently, patients can see from an activity diary that they have been accomplishing more or obtaining more pleasure than they had realised. Any biases in the depressive thinking that filter out signs of satis-faction or pleasure can thus be countered by actively noting and recording in this fashion. Focusing attention on the satisfaction obtained from any activity in this way frequently leads directly to a lift in mood. When patients realise that engaging in some activities can result in some satisfaction, this can also help to counter the hopelessness that results from thinking that nothing will do them any good.
Scheduling Activities
Monitoring of activities enables identification of those activities that are associated with low mood and those that are most likely to be accompa-nied by some positive feelings. From this, patients can be helped to plan their days in order to maximise the likelihood of obtaining more satisfac-tion. This technique, known as activity scheduling, hinges around planning small tasks that it is feasible to accomplish even with depression. Activities and tasks are usually written down on a daily plan for the coming few days, which is initially completed in the session with the therapist’s assistance.
Depending on the patient’s degree of impairment, the plan can be com-pleted for small activities on an hour-by-hour basis (e.g. get dressed, make cup of coffee) or for more general activities (e.g. go shopping) over more extended periods. Where patients are suffering from low levels of energy, it is helpful actively to schedule rests as a reward for small accomplish-ments. As the patients’ levels of activity increase, so does the possibility of their gaining at least some satisfaction from the tasks they have attempted.
Planning the time in this way also directly or indirectly limits the time
the patients spend sitting ruminating about their perceived shortcomings, which can be beneficial.
Graded Task Assignment
As depression makes attempting most tasks more difficult, many tasks may need to be broken down and attempted in a graded fashion. If the degree of impairment demands it, the graded assignment of tasks may initially need to focus on small everyday activities, such as getting dressed. Gradually the patient may become more able to address more daunting tasks that had previously been avoided, such as more complex work tasks or negotiating the management of household bills or debts. With tasks that are likely to be seen as aversive, helping the patient to focus on any satisfaction obtained from accomplishing any steps is crucial to improving mood. For the patient to address tasks in this gradual fashion can help to counter avoidance.
Tackling tasks that had previously been avoided can help the patient to develop more of a sense of control over their problems, which can further erode the hopelessness and helplessness inherent in depression.
BEHAVIOURAL TECHNIQUES IN PERSISTENT DEPRESSION
When attempting to use these behavioural techniques with people suf-fering from chronic depression, many difficulties can become evident.
Monitoring of activities requires gaining reasonably precise information about feelings and behaviours. As was described in the previous chapters, patients with persistent depression often do not wish to think about their experiences or their moods in any detail. They are often poor at providing precise information about their depression. Useful information may there-fore be hard to come by during the session, and the patients may also find it hard to complete any kind of diary for monitoring their feelings and activi-ties between sessions. Activity scheduling often focuses directly on increas-ing activity levels. However, many persistently depressed individuals are already quite active and the strategy of simply fostering re-engagement in previously satisfying activity does not readily apply. In addition, many of the activities that are completed result in little pleasure or mastery, so there is also less scope for simply refocusing the patient’s attention on positive feelings that might be available. Further, the avoidance of particularly difficult tasks may be accompanied by such a conviction that, if the therapist even suggests that the task should be considered, it
may threaten the therapeutic relationship. Such entrenched avoidance can make graded task assignment difficult.
The Benefits of Persistence
Faced with such difficulties, it can be tempting to abandon these standard behavioural strategies in favour of more complex and sophisticated psy-chological interventions. The influence of long-held attitudes and beliefs on avoidance in persistent depression is often evident. Therefore, changes in behaviour will indeed be harder to achieve than when working with the inactivity induced by low mood in acute depression. However, it is rarely the case that behavioural techniques for increasing satisfaction can-not work at all. The problem in persistent depression is more usually that patients either decline to engage in activities or dismiss any small benefits that result from them. When patients can be induced to engage in appro-priate activities, small benefits can result. The challenge for the therapist is to highlight the patient’s avoidance and to foster some engagement from the patient. Rather than abandoning the use of these techniques in the face of the difficulties presented by chronic depression, it can be more help-ful to persist with the approach and adapt it to the particular difficulty encountered.
As in acute depression, engagement in appropriate activities can lead to increases in satisfaction and to some alleviation of depressed mood. As changes may be small, they may be overlooked or dismissed by the patient.
The therapist needs to be alert to this and to respond enthusiastically to any positive shift. The therapist’s response can serve to reinforce the small-est signs of change that the patient has made. It can also make the patient more aware of their tendency to dismiss any progress. Where the patient initially finds it hard to see the utility of such small changes, the training this process provides in attending to small shifts in mood can be a valuable building block in the gradual progress of therapy. The experience of engag-ing in and attendengag-ing in detail to specific experiences can help to counter the overgeneral style of thinking common in persistent depression. This training in processing specific, small experiences is essential to the process of addressing behavioural, cognitive and emotional avoidance in a gradual fashion.
Even when behavioural techniques are not successful in directly improv-ing the patient’s mood, they are important in the overall therapeutic strategy with persistent depression. Where difficulties are encountered in implementing desired behaviours, blocks to progress can be identified.
This provides an opportunity to build a shared formulation of precisely how the problems affect day-to-day tasks. If the therapist can help the patient to make sense of the difficulties they are encountering, this con-stitutes an important step in addressing the problems. In particular, the patient can be helped to see that they are avoiding certain activities or issues and the precise ways in which they are doing so. The potential drawbacks of avoidance in specific situations can then be made evident. Difficulties in implementing behavioural techniques can be used to begin to highlight the role that thoughts or beliefs may have in maintaining the depression.
Shedding light on how beliefs may be interfering with everyday tasks can be helpful in itself. For example, one young woman was having great diffi-culty re-instating some of the social activities that she had enjoyed prior to becoming depressed. Discussion of the difficulty suggested that it resulted in large part from a belief that she was worthless and so did not deserve to enjoy herself. Once this had been identified, she made some progress in scheduling activities despite her view that she did not deserve to enjoy herself, even without attempting to modify this belief. Even where such quick change does not occur, highlighting the role of avoidance and beliefs in blocking desired outcomes provides an important foundation for later attempts to identify and modify the underlying beliefs.
PROBLEMS IN MONITORING ACTIVITIES AND LEVELS OF MASTERY AND PLEASURE
Early in therapy, patients with depression are often asked to keep a diary of their daily activities and rate each activity for levels of mastery and plea-sure, for example on a ten-point scale. This helps to focus the patient’s atten-tion on what they have done and the pleasure or satisfacatten-tion that resulted.
Countering the negative mental filter imposed by depressive information processing in this way can help directly to lift depressed mood. It is also helpful in identifying factors that might be contributing to low mood and that might serve as possible targets for further intervention. These factors include generally low levels of activity, lack of engagement in previously pleasurable or satisfying activities, and specific triggers of low mood.
Problem: Patients have Great Difficulty Completing a Diary of Activity or do not Complete it at All
We have discussed how avoidance is a common coping response in chron-ically depressed patients, which is used as a means of reducing perceived stress. It is inevitable that avoidance will impact on the performance of
tasks within the therapy as well as those from the patient’s everyday life outside. As completing a diary involves both effort and the possibility of having to focus on distressing situations, the patient’s habitual response to stress may result in the diary not being completed.
Don’t
rGive up on monitoring of activities
rConclude that the patient is too unmotivated to make progress
rPressurise or lecture the patient that not doing therapy tasks will prevent them from getting better, as this will likely reinforce conclusions that try-ing anythtry-ing makes them feel worse and that failure is the only possible outcome
Do
rFind out more about the reasons for the difficulty rSimplify the monitoring procedure
rModel the activity monitoring in session
rFrame the task as an experiment to find out more about the difficulties.
Patients typically make negative predictions regarding the perceived catas-trophic consequences of engaging in avoided activities, including diary-keeping. The therapist aims to work with the patient to identify these predictions and to establish behavioural experiments to test out their validity. This is often easier said than done. The therapy extract below illus-trates how the use of avoidance as a coping strategy interferes with diary-keeping and needs to be actively addressed if progress is to be made. In this example, the therapist attempts to help Marion to see the link between her not attempting the diary and her prediction that recording inactivity would make her feel worse. The therapist then tries to help her to begin to question this prediction.
T: So Marion, how did you get on with keeping a record of your activities like we agreed?
M: I haven’t done it.
T: What stopped you doing it?
M: I don’t do anything so there was nothing to write.
T: I think we discussed that as a possible obstacle last week didn’t we and we agreed things like getting up and sitting in the chair, eating, drinking, sleeping are all activities?
M: (nods)
T: Sounds like you find the whole idea of writing down what you are doing difficult. Let’s talk about that. Did you put the diary on the coffee table as we agreed?
M: I did. I even wrote one thing on it. But then I felt terrible.
T: Did you bring the diary with you?
M: No. It’s only got one thing on it.
T: But you did make a start. You said you felt terrible after writing that one thing. Can you remember what you wrote?
M: Got up, had a cup of tea and sat watching TV.
T: Can you recall what it was about writing those things that made you feel so terrible?
M: It just shows how pathetic I am. I do nothing all day. I know that. I don’t need to keep a diary to remind me of the fact—I’ll just feel worse.
T: So, when you made one entry on the diary sheet this triggered a whole host of thoughts in your mind such as ‘I’m pathetic’, ‘I don’t do any-thing all day’ and you thought that completing the diary won’t help.
In fact you thought it would make you feel worse because it would remind you of how inactive you are.
M: Exactly. Things are better if I try not to think too deeply about them.
T: Well, you said when you made the one record on the diary sheet you felt terrible. Can you describe terrible?
M: What do you mean?
T: Well, when you were filling it in did you notice any physical sensations in your body?
M: I don’t think so.
T: Okay, Marion I’d like with your help to try a small experiment here in the session. I’ve got here a blank diary sheet like the one we used last week. What do you think would happen if you tried now to complete the diary sheet just recording what you have done so far today?
M: What, now?
T: Yes.
M: I’ll feel terrible.
T: Would you be willing to have a go? It might help us to find out impor-tant information about your problems.
M: Like what?
T: Exactly what feeling terrible is like for you and how this gets in the way of completing the diary (hands Marion the activity schedule and a pen.)
M: (starts to write, hands shaking) Look at me—I feel terrible. My hands are shaking. I can’t write. My writing is just scrawl. You won’t be able to read it, it’s pointless.
T: Well done for having a go. It didn’t look easy. Okay, so having a go right now makes you shake, and all these thoughts crowd your mind.
How are you feeling right now?
M: Anxious. It’s how I always feel when I try and do anything.
T: Okay so would it be fair to say not keeping the diary stops you getting anxious?
M: If you put it like that then, yes.
T: So one advantage of not keeping the diary is you avoid getting anxious.
Any other advantages?
M: Well thinking about it in those terms whenever I try to do anything I always feel awful and give up before I’ve finished it. Giving up on things always makes me feel really down, so often I think it’s best not to start then I don’t feel such a failure.
T: So another advantage is you avoid running the risk of failing?
M: Yes.
T: Can I ask if there are any disadvantages to using this avoidance tactic?
M: Yes, as a result I do nothing.
T: What is the effect on your mood of doing nothing?
M: I feel terrible.
T: So it seems the avoidance keeps you stuck between the devil and the deep blue sea. If you try and do things to improve your mood, you feel anxious and so not doing it is your way of reducing your anxiety.
However, avoiding doing things makes you feel more depressed.
M: Yes. And so it goes on. Can you see why I try not to think about things?
It’s the only answer.
T: It’s interesting what you say there. You’ve already talked about avoid-ing doavoid-ing certain thavoid-ings when you feel anxious and just then you talked about trying not to think about things. Is that also avoidance?
M: I’ve never really thought about it. I guess so.
T: Well, we have learned quite a bit about how you might use avoidance to reduce the impact the unpleasant thoughts you experience and those seemingly overwhelming feelings of anxiety and depression have on you. It certainly makes sense of why keeping the diary was difficult.
M: Oh. So, I’m not wasting your time?
T: This is your time Marion. How about if we focused our efforts on trying to find a way of reducing the avoidance?
M: Does that mean I’ll have to try and do things?
T: Yes, but gradually.
M: I don’t think I can.
T: Let’s see how we go. What we need is a starting point. What activities have you enjoyed in the past?
In this extract, the avoidance that has interfered with the diary-keeping is identified and framed as a problem to be addressed collaboratively. Al-though little progress appears to have been made in terms of getting the patient to record their activity or to agree to schedule specific activities, the focus has been shifted from avoidance as being an obstacle to the therapy to avoidance as being a problem to be addressed. A start has been made in pinpointing how negative evaluations trigger negative feelings, which