COGNITIVE BEHAVIOR THERAPY
A: You will provide education, set up behavioral experiments to help patients test their thoughts, and use an activity chart, as below
Behavioral Activation 89 paTienT: Okay.
TherapisT: In fact, I’d like you to give yourself credit whenever you do something active—that is, whenever you’re not napping or watching TV or surfing the Web. [See pages 274–276 for a further description of giving oneself credit.]
In this segment, I lead Sally to draw conclusions from a review of her typical day. Some patients need more guidance than others to do this (e.g., “Do you notice how much time you spend in bed? What is your mood like when you get up—do you feel much better? What changes do you think you might like to try this week?”). I guide Sally to commit to implementing specific changes and identify automatic thoughts that might interfere, proposing behavioral experiments to test the validity of her negative predictions. I also ask her to give herself credit when- ever she is active.
Q: What if . . . patients believe they are incapable of becoming more active, or that becoming more active will not improve their mood?
A: You will provide education, set up behavioral experiments to help
TherapisT: You know, that’s exactly what most people with depres- sion say. But research shows us that it’s actually the opposite.
The way people get over their depression is to get more active first—then they start to feel better.
paTienT: Oh.
TherapisT: Would you be willing to do an experiment this week—
to see whether you’re too tired, and to see what happens to your mood if you do try to do more things?
paTienT: I guess so.
TherapisT: Let’s see. [providing a contrast among energy required for various activities] What are some things you know for sure would be too hard? Running? Doing errands for an entire day? Cleaning up your whole apartment?
paTienT: Yeah, I couldn’t do those things.
TherapisT: So what’s something on the other side, something that takes just a little energy?
paTienT: (Sighs.) I could go to the library. Return my overdue book and maybe get some DVDs.
TherapisT: [providing positive reinforcement] Good idea! What else could you do?
paTienT: I’m not sure.
TherapisT: Do you think you could do a few tasks a day—if they were only for 10 minutes each?
paTienT: I guess I could.
TherapisT: Good.
The therapist helps the patient specify these tasks and con- tinues to elicit additional activities, then requests that the patient use an activity chart.
TherapisT: These are all good activities. (pulling out the Activity Chart in Figure 6.2) I’d like to figure out with you when you might do these things. Is it okay if we write them down on this chart?
paTienT: Okay.
TherapisT: (looking at the description of the patient’s typical day) So, it looks as if you usually get up around 11:00 or 11:30. What would you think about getting up by 10:00 and 10:30 in the morning?
91
mON.TUE.WED.THU.fRI.SAT.SUN.
morn
6–7Sleep 7–8Sleep 8–9Sleep ing 9–10Sleep 10–11Get up/shower/ dress 11–12Breakfast Kitchen cleanup—10 min
Afte rno
12–1TV Newspaper on 1–2Errand or window- shopping 2–3Rest (cont.) FIGURE 6.2.Initial (partial) Activity Chart for a more severely depressed patient. From J. S. Beck (2011). Copyright 2011 by Judith S. Beck. Adapted by permission.
92
mON.TUE.WED.THU.fRI.SAT.SU
Afte rno
3–4TV Lunch Kitchen on cleanup—10 min 4–5Call sister Laundry—10 min 5–6TV Walk
Even
6–7Rest Laundry—10 min 7–8Dinner Kitchen cleanup—10 min 8–9Call Jonathan E-mail ing 9–10YouTube Surf Web 10–11Read 11–12Get in bed Sleep 12–1Sleep FIGURE 6.2. (cont.)
Behavioral Activation 93 paTienT: I could do that.
TherapisT: What would be good to do next?
paTienT: Take a shower, I guess. Get dressed. Have breakfast.
TherapisT: So that’s a change from what you usually do?
paTienT: Yeah, sometimes I don’t get dressed all day.
TherapisT: How about if you write down, in the 10 o’clock space,
“Get up, shower, get dressed.” And then write “Have break- fast” in the 11 o’clock space.” [See Figure 6.2.]
paTienT: Okay. (Does so.)
TherapisT: Now, what do want to do after breakfast? Wash your breakfast dishes?
paTienT: I should. I’ve been letting dishes pile up in the sink. The kitchen is kind of a mess.
TherapisT: So, how about doing dishes or cleaning up the kitchen for 10 minutes? You don’t have to finish everything at once.
paTienT: (sigh of relief) Okay.
TherapisT: And then after the dishes? Do you want to take a break, watch TV or read the newspaper or surf the Web like you usually do?
paTienT: Yeah, that would be good.
TherapisT: Okay, so in the 11 o’clock space, let’s put “clean kitchen for 10 minutes,” and in the 12 o’clock space put “TV or news- paper or surf the Web.”
The therapist and patient continue in this vein until they have made a schedule for the next day. Because the patient has been so inactive, the therapist takes care not to overwhelm him by creat- ing too busy a schedule. She builds in short periods of activity with longer periods of leisure activity or rest. She also asks the patient to give himself credit every time he follows the schedule. Next she asks the patient if he is willing to try to follow the same basic schedule every day. They make lists of potential tasks the patient could do at home, people he could call, and places he could go.
At the following session, the therapist reviews this homework assignment of following the schedule. She asks the patient about his previous predictions: that he would be too tired to do activi- ties and that they would not help. Discovering that his automatic thoughts were inaccurate can motivate the patient to get up ear- lier and engage in a greater number of productive or pleasurable activities.
Q: What if . . . patients can’t come up with any pleasurable activities?