COGNITIVE BEHAVIOR THERAPY
A: There are many lists from which patients can choose activities
Q: What if . . . patients can’t come up with any pleasurable activities?
Behavioral Activation 95 TherapisT: I have two theories. One, you had interfering auto- matic thoughts. And/or two, maybe you did experience slight mood changes, but you either didn’t notice them or don’t remember them.
paTienT: I don’t know.
The therapist then elicits the cognitions the patient had when engaging in various activities and helps him respond to them, in anticipation of their re-occurrence in the coming week. The ther- apist also ascertains that the patient had neglected to give himself credit. Next they decide to have the patient rate the sense of mas- tery and pleasure he gets.
TherapisT: Suppose we make up a pleasure scale first so you’ll have a guideline to rate your activities [see Figure 6.3]. Now on a scale from 0 to 10, what activity would you call a 10? An activity that has given you great pleasure or that you could imagine giving you great pleasure?
paTienT: Oh, I guess that would be when I went to the champion- ship game [of his home football team].
TherapisT: Okay, next to “10” write “At football game” on the chart.
paTienT: (Does so.)
TherapisT: Now, what would you call a 0? An activity that gives you absolutely no pleasure?
paTienT: That would be arguing with my partner.
TherapisT: All right, write that next to 0.
paTienT: (Does so.)
TherapisT: And what would be something midway in between?
Pleasure Mastery
10 Arguing with partner Building the deck 5 Dinner with brother Raking leaves last year 0 At football game Bouncing a check
FIGURE 6.3. Pleasure and Mastery Rating Scale.
paTienT: I guess . . . having dinner with my brother.
TherapisT: Good, write that.
If the patient can easily match activities with numbers, these three anchor points are usually sufficient, although the patient can add more points if desired. If the patient has difficulty with numbers, you can change the anchor points to “low,” “medium,”
and “high.” After completing the pleasure scale, the patient fills out the accomplishment scale in the same way. Next the therapist asks the patient to use his scales to rate today’s activities.
TherapisT: That’s good. Now let’s have you fill in a little of today’s schedule. Here—it’s the 11 o’clock block—write “therapy”
and under that, “A = ” and “P = .”
Now how much of a sense of accomplishment or mastery have you felt during therapy today?
paTienT: About a 3.
TherapisT: And pleasure?
paTienT: About a 2. (Fills in the blocks.)
TherapisT: And what did you do in the hour right before therapy today?
paTienT: I went to the bookstore.
TherapisT: Okay. Write “bookstore” in the 10 o’clock block. Now, look at the scale. How much of a sense of accomplishment did you get during that hour?
paTienT: Maybe 2 or 3. (Writes it down.) I found the book I wanted.
TherapisT: And pleasure?
paTienT: None, really.
TherapisT: So being at the bookstore was like arguing with your partner?
paTienT: No, I guess it was about a 2.
TherapisT: But isn’t that interesting? Your first reaction was that you got no pleasure at all. The depression probably interferes with recognizing, or maybe remembering, pleasurable activi- ties. That’s why I think it’s worth your keeping this activity chart this week, to find out whether some activities are better than others. (pause) Do you think you’re straight on what to do?
Behavioral Activation 97 paTienT: Yeah.
TherapisT: Could you tell me why it might be worth the effort to do all this?
paTienT: Well, it sounds like you’re saying that maybe my mood does change some, based on what I’m doing.
TherapisT: What do you think?
paTienT: I guess that could be right.
TherapisT: If that’s true, we can try to schedule more activities that do make you feel better next week. Now, the ideal thing would be to have you fill this out as close to the time you fin- ish an activity as you can—so you won’t forget what you did, and so your ratings will be more accurate. If that’s impossible, could you try to fill this out at lunch, dinner, and bedtime?
paTienT: Yeah, it shouldn’t be a problem.
TherapisT: And if you can fill it out every day, that would give us the most information. But even if you just do a couple of days, that would give us some. Now one last thing. How about if you look over the activity chart the day before our next session?
See if there are any patterns, or anything you can learn from it. You can write down your conclusions on the back if you want. Okay?
paTienT: Okay.
USING THE ACTIVITY CHART TO ASSESS THE ACCURACY Of PREDICTIONS
When patients are skeptical that scheduling activities can help, you can ask them to predict levels of mastery and pleasure or mood on one activ- ity chart and then record actual ratings on another. These comparisons can be a useful source of data.
TherapisT: Let’s take a look now at your predictions on the first activ- ity chart and what actually happened on the second one.
paTienT: (Nods.)
TherapisT: Let’s see . . . it looks as if you predicted very low scores, mostly 0’s to 3’s, for these three times you scheduled to meet your friends. What did happen?
paTienT: Actually, I had a better time than I’d thought—my pleasure scores were 3’s to 5’s.
TherapisT: What does that tell you?
paTienT: I guess I’m not a good predictor. I thought I wouldn’t enjoy myself, but I did, at least some.
TherapisT: Would you like to schedule more social activities for this coming week?
paTienT: Yes, I should.
TherapisT: Good. Do you see what could have happened—and, in fact, what was happening before you came to therapy? You kept predicting that you’d have a lousy time with your friends so you didn’t make any plans; in fact, you turned down their invitations. It sounds as if this therapy homework helped you test your ideas; you found it was wrong that you’d have a lousy time, and now it sounds as if you’re more willing to schedule more. Is that right?
paTienT: Yes. But that reminds me, I wanted to talk about one predic- tion that actually turned out worse.
TherapisT: Okay, when was that?
paTienT: I predicted that I’d get 4’s in accomplishment and pleasure when I went running over the weekend. But both were 1’s.
TherapisT: Do you have any idea why?
paTienT: Not really.
TherapisT: How were you feeling when you were running?
paTienT: Mostly frustrated.
TherapisT: And what was going through your mind?
paTienT: I don’t know. I wasn’t feeling very good. I got winded real eas- ily. I couldn’t believe how hard it was.
TherapisT: Did you have thoughts like that—”I don’t feel very good,”
“I’m winded,” “This is hard”?
paTienT: Yeah, I think so.
TherapisT: Anything else go through your mind?
paTienT: I remembered how it used to be. I could go 2 or 3 miles with- out getting too winded.
TherapisT: Did you have a memory, an image of how it used to be?
paTienT: Yeah. It was easy. I’m in really bad shape now. It’s going to be so hard to get back in shape. I’m not sure I’ll ever be able to get back in shape.
TherapisT: Okay, let me see if I understand. [summarizing] Here in my office you thought you’d get a moderate sense of accomplish- ment and pleasure when you went running. But instead, you got very little. It sounds as if you had a memory of how it used to be and
Behavioral Activation 99 you also had thoughts that interfered, such as, “This is hard,” “I’m real winded,” “I used to do this easily,” “I’m in such bad shape now,”
“Maybe I’ll never be able to get back in shape.” And these thoughts made you feel frustrated. Does that sound right?
paTienT: Yeah.
In this last part, the therapist uses the activity chart as a vehicle for identifying a number of automatic thoughts that were undermining the patient’s enjoyment of an activity. In the next part, the therapist will:
1. Help him evaluate a key cognition, “Maybe I’ll never be able to get back in shape.”
2. Teach him to compare himself to how he was at his worst point instead of his best point, so he can feel good about running instead of being so self-critical.
Behavioral activation is essential for most depressed patients. Many patients need only to be provided with a rationale, guidance in select- ing and scheduling activities, and responses to predicted automatic thoughts that might interfere with implementing the activities or with gaining a sense of pleasure or mastery from them. Therapists often need to be gently persistent in helping patients become more active.
Patients who are quite inactive initially benefit from learning how to create and adhere to a daily schedule with increasing degrees of activ- ity. Patients who are skeptical about scheduling activities may benefit from doing behavioral experiments to test their ideas, and/or checking the accuracy of their automatic thoughts by comparing their predic- tions to what actually occurs.
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