Behavioral Activation Adapted from C Martells BA Manual

Behavioral Activation (Adapted from C. Martell’s BA Manual & Trainings) Abigail Eiler, LMSW, CMHP, QMHP, ASIST-11 Registered Trainer October 16, 2015

Behavioral Health in PC �“In 2010, 20% of all visits to primary care physicians included at least one of the following mental health indicators: depression screening, counseling, a mental health diagnosis or reason for visit, psychotherapy, or provision of a psychotropic drug. ” (2010, National Ambulatory Medical Care Survey). �“…primary care physicians remain the point of entry into the behavioral health system, even when managed behavioral health care organizations [such as MHNet] are in place. ” (2000, American Psychiatric Association’s (APA) Practice Guideline). �Patients are less likely to follow-up on behavioral health referrals. Completing a brief intervention during a primary care encounter will help promote healthy, effective behaviors can improve mental health outcomes.

What is Behavioral Activation? �Brief psychosocial-spiritual therapeutic approach. �Developed and identified as a 3 rd Generation behavioral therapy. �Based on Charles Fester’s Functional Analysis of Depression (70 s). �Structured and addresses problems and behaviors associated with various disorders: �*Depression �Anxiety �PTSD

What is the purpose of BA? �Increase environmental reinforcement �Reduce punishment �Decrease depressive symptoms �Decrease anxiety �Create “helpful disruptions” in cyclical thinking �Addresses automatic thoughts in the behavior changing process.

Introducing your Pt to BA �Orient to treatment rationale and approach �Develop initial treatment goals �Behavioral analyses (**think cause and effect**) �Repeated application of activation while promoting engagement strategies �Between you and the client (Modeling) �Between the client and others �Ongoing troubleshooting �Treatment review and relapse prevention

Developing Positive Replacement Behaviors � After educating a client about behavioral activation : �Make a long list of positive replacements �Do this prior to starting your assessment and goal setting �Remember – create a foundation for success in the BA model.

Strategies Involved in the Delivery of BA �Structuring strategies (including orienting to treatment) �Assessment strategies (individualizing primary treatment targets through behavioral assessment) �Activation strategies (activity structuring and scheduling) �Targeting avoidance, routine disruption, rumination

Assessment � Identify activity level within the patient’s natural environment � Discuss possible goals and select which ones to start with for homework. � (Remember: select the easiest goals first) � Define and specifically describe problems in behavioral terms (Ask exploratory questions) � Assess consequences of behavior � Examine behavioral patterns

Goal Setting �Ultimate goal of treatment: Clients modify their behavior to increase contact with sources of positive reinforcement �Typical goals relate to changing avoidance patterns and routine disruption and to changing environmental context �Focus on acting from the “outside in” �Set priorities for long and short-term goals �Figure out what behaviors are needed to reach goal— what, when, where, etc. Be focused, specific, and concrete!

Problem Solving �Problem definition �Generate and evaluate solutions �Practice new behaviors in session as appropriate �Skills training as appropriate �Troubleshooting

Activity Scheduling �Purpose: �Increase pleasure �Increase involvement in daily activities �Increase approach (vs. avoidance) �Increase awareness of mood �Typically uses a rating scale from 0 -10 �Patients will document the number of activities per day (aim for 2 – 5) **REFER TO HANDOUT

Structure of Sessions �Set collaborative agenda �Review homework �Review weekly activities �Troubleshoot problem behaviors �Identify �Brainstorm �Resolve & plan for the future �Assign new homework �Ask for feedback

Blocking Avoidance �Orient patient to avoidance (how it works in short run and long run) �Identify behaviors that function as avoidance �Help patient engage in alternative behaviors

TRAP – This is what we don’t want Trigger Response Avoidance. Pattern

TRAC – This is what we want to achieve!!! Trigger Response Alternative Coping

ACTION Strategy �Assess �Choose �Try �Integrate �Observe �Now How will my behavior affect my depression? Am I avoiding? What are my goals in this situation? I know that activating myself will increase my chances of improving my life situation and mood. Therefore, if I choose not to self-activate, I am choosing to take a break. Try the behavior I have chosen. Integrate any new activity into my daily routine. Observe the result. Do I feel better or worse? Did this action allow me to take steps toward improving my situation? Now evaluate; OR Never give up.

Targeting Ruminating �Attention to experience strategies �Identify physical responses � notice colors, smells, noises, sights, etc. �participate in new tasks �Select high engagement activities

Relapse Prevention �Consolidate Treatment gains �What has been helpful? �What has been learned? �Plan for future problems �What targets have been identified �What new responses to targets are practiced

Challenges/Considerations �Clients may identify things that are unattainable/unrealistic. �Clients goals don’t offer enough direction to motivate behavior changes. �Clients share activities that they thinks other want them to focus on. �In doing behavioral activation, sometimes people identify activities that are important to other people. Basically, people identify activities based on what they think they should be doing as opposed to what they want to do. �If you come up with activities that are not important to you, it is going to be difficult to foster motivation and to really feel connected to the activities you are engaging in. �When identifying activities for behavioral activation, try to think of what is uniquely important to you. What matters to you?

References �Depression in Context (Martell, Addis, Jacobson, 2001), NY: WW Norton & Company, Inc. �Overcoming Depression One Step at a Time (Addis & Martell, 2004), Oakland, CA: New Harbinger, Inc. �Behavioral Activation for Depression: A Clinician’s Guide (Martell, Dimidjian, Herman-Dunn & Lewinsohn, 2010), NY: Guilford Press