behavioral activation for depression 343 · other people have stressful things in their lives and...

signments are both important predictors ofoutcome in BA. Moreover, it is important tonote that we used a number of client character-istics as exclusionary criteria in our treatmentresearch. For instance, if a client was acutelysuicidal, such that his or her risk could not bemanaged on an outpatient basis, then wewould refer him or her for more acute and in-tensive treatment. In addition, if a client had acomorbid diagnostic disorder that was moresevere and prominent (more interfering and theprimary focus of the client), and necessi-tated another evidence-based treatment (e.g.,obsessive–compulsive disorder), then we wouldalso refer him or her to a more specifically ap-propriate treatment. We also carefully evalu-ated any potential medical problems that mayhave contributed to depression and referred cli-ents for appropriate concurrent medical treat-ment, if necessary.

CASE STUDY

Background Information

The following section presents the treatment ofMark, a 43-year-old man with a long history ofdepression, who sought treatment after the endof his second marriage. Mark was in treatmentfor 19 sessions across 4 months. The descrip-tion here is presented to illustrate the imple-mentation of core BA principles and strategies.Earlier sessions are described in greater detailto provide the reader with “how-to” informa-tion regarding the primary principles and strat-egies. Later sessions emphasize a thematic fo-cus for which the same types of principles andstrategies are applied. It is important to empha-size at the outset that this case description isnot intended to communicate a prescriptivecourse of treatment, and readers are advisedagainst following the sequence of strategies in alockstep fashion. BA is a highly idiographictreatment in which the choice of specific activa-tion strategies is driven by functional analysis;given this, the reader is encouraged to attend tothe ways the therapist conceptualizes Mark’sdifficulties and implements treatment strategiesover the course of therapy. It is our hope thatthis detailed illustration will inspire readers toapply the basic principles and core strategies ina flexible and idiographic manner.

Mark sought treatment at the urging of hisprimary care physician. His recent episode ofdepression had lasted without remission for 3

years. Mark also had a history of alcoholabuse. His early alcohol abuse had caused sig-nificant problems in Mark’s first marriage,which ended in divorce when he was in hisearly 20s; however, problems with alcoholwere not a cause of current concern. He hadbeen in therapy previously, during his separa-tion and divorce 4 years earlier. However,Mark described it as unstructured and un-focused, and reported that he stopped going af-ter a few sessions. He lived alone, although hehad joint custody of his twin adolescent daugh-ters; he and his ex-wife alternated parenting ev-ery other week.

Mark reported that he had had periods ofdepression for “as long as I can remember.” Inparticular, he recalled his first episode of de-pression at age 12, shortly after his fatherabruptly left and severed all contact with Markand his family. Mark reported that he had be-lieved that his parents were happily marriedand, at that time, blamed himself for his fa-ther’s departure. Mark reported that hismother and older siblings never discussed hisfather. In describing his mood during adoles-cence and adulthood, he reported, “I have peri-ods when I’m able to function OK. I go to workand all that, but I’m never really happy.”Mark’s primary depressive symptoms includeddepressed mood, loss of pleasure in nearly allactivities, excessive guilt, fatigue, difficultyconcentrating, and occasional passive thoughtsof death.

Mark had had a social network that re-volved primarily around his former marriage,but he had been withdrawn from that networksince his separation and divorce. Currently, hespent most of his time alone, with the excep-tion of caring for his daughters. Mark was col-lege educated and worked as an accountant fora local manufacturing company. He also wrotechildren’s stories and, prior to his most recentepisode of depression, was working on a num-ber of stories as a member of a local writer’sgroup.

Case Conceptualizationand Overview of Treatment

Mark’s depression was conceptualized as beingcontrolled by a pattern of interpersonal avoid-ance that was negatively reinforced by reduc-tions in grief and anxiety. Specifically, Markhad trouble fully engaging in his significant re-lationships and, instead, avoided intimacy in

Behavioral Activation for Depression 343

From Clinical Handbook of Psychological Disorders, Fourth Edition, Edited by David H. Barlow Copyright 2008 by The Guilford Press. All rights reserved.

Copyright © 2008 The Guilford Press. All rights reserved under International Copyright Convention. No part of this text may be reproduced, transmitted, downloaded, or stored in or introduced into any information storage or retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereinafter invented, without the written permission of The Guilford Press.

Guilford Publications 370 Seventh Ave., Ste 1200

New York, NY 10001 212-431-9800800-365-7006

www.guilford.com

various ways that included ruminating aboutmistakes he made in the past, and failing to ex-press commitment to the relationship and whathe thought or felt about various topics on aregular basis. Over the course of treatment, thetherapist and Mark hypothesized that avoidingclose interpersonal connections in his adult lifekept Mark detached enough that he would notfeel subsequent losses as acutely as those he feltas a child. However, these patterns of avoid-ance also maintained his depression by limitingMark’s experience of reward in many of hiscurrent contexts. Treatment focused initially onincreasing activation and addressing many sec-ondary problems and routine disruptions thathad become established. Although Mark in-creased activation relatively quickly, his mooddid not improve significantly. This led to a pri-mary focus on Mark’s rumination and the waysit functioned to avoid intimacy in his relation-ships, and experimentation with new behaviorsdesigned to move Mark closer to his goal ofhaving a close intimate relationship.

Session 1

Session 1 focused on reviewing the results fromthe assessment process, presenting the treat-ment model, encouraging questions and feed-back, and tailoring the model to Mark’s spe-cific experiences. The review of the assessmentprocess is typically brief; in this part of the ses-sion, the aim of the therapist is to ensure thathe or she has a solid understanding of the cli-ent’s presenting problems, relevant history, andprevious experience with treatment, if any. Thetherapist also reviews the basic diagnostic for-mulation to ensure that the assessment out-come matches the client’s subjective experienceof his or her current problems. Discussion ofthe treatment typically forms the bulk of theearly sessions. The following transcript pro-vides an example of the therapist presenting thetreatment model and responding to frequentlyasked questions about the etiology of depres-sion. Specifically, the therapist puts forth theidea that depression is treated behaviorally, re-gardless of etiology.

THERAPIST: Let me tell you a little about the ba-sic model that guides BA. The first idea isthat there are often things that happen inpeople’s lives that make it hard for them toconnect with the kinds of experiences thatwould normally help them feel good. These

shifts can be clear and easy to detect changeslike major losses or disruptions in life. Andthey can also be smaller things, like the kindof things that just bug you a little but theykeep happening, or you have a bunch ofthem happen all around the same period oftime. The most important part is the ideathat the effect of these events in your life isthat it’s harder to connect with the kinds ofexperiences that could give you a sense ofpleasure or accomplishment in your life, andthat could help you feel better.

MARK: I would say that is true for me. There is-n’t much that helps me feel better. Eventhings that I think should help me feel betterdon’t do much.

THERAPIST: Yes, exactly. What we find oftenhappens is that people can respond to thesechanges by pulling away from their liveseven more. This pulling away can happensometimes in obvious ways, like staying inbed or calling in sick to work, or cancelingsocial engagements, and sometimes in moresubtle ways, like being focused more on yourthinking than on the activities you are en-gaged in. The problem with pulling awaylike this is that it tends to keep people stuckin feeling depressed, and the pulling awaycan become a problem in its own right. So,the ultimate goal of our work together is tofigure out what sorts of experiences may po-tentially have a positive effect on your mood,and then help you activate and engage toconnect with these experiences. And to fig-ure out how to solve the problems that arecreating stress or dissatisfaction in your life.How do you see this fitting with your experi-ence? Do you have questions about what I’vesaid? Parts that fit or don’t fit?

MARK: I understand what you are saying, and Ithink some of it fits, but I guess I don’t un-derstand why I get so depressed. I mean,other people have stressful things in theirlives and they seem to function. Other peo-ple get divorced or have crappy jobs, andthey move on. I mean, come on, I’ve been di-vorced for 4 years now. I think depressionruns in my family. My older brother has beendepressed forever, and I sometimes wonder ifmy dad was depressed when he took off.Sometimes, I can’t really identify anythingthat has happened in my life. I mean, I amnever really happy and then, it’s just like aswitch goes in my brain and I’m back in that

344 CLINICAL HANDBOOK OF PSYCHOLOGICAL DISORDERS




New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

dark hole again. But how does that fit withwhat you are saying?

THERAPIST: That is an excellent question. WhatI mean as I talk about depression is thatsome people are more vulnerable than oth-ers. And, there are many ways that you maybe vulnerable to depression—through genet-ics, biology, or experiences in your history.What this treatment emphasizes is that it’spossible to change depression by makingchanges in what you do.

MARK: That makes sense to me. One part ofwhat you said definitely fits for me—the partabout pulling away more. I definitely dothat. Sometimes I don’t talk to another per-son or get out of bed all weekend. I know itmakes it all worse. But I still do it. I guess Idon’t really understand that part either. Itfits, but it doesn’t make much sense to me.

As the therapist replies to these very com-mon questions, she seeks to normalize avoidantresponses to depression. It is essential for theclient to experience the therapist as someonewho understands and has sincere empathy forhis or her struggle. The therapist must commu-nicate that the client’s behaviors make sense,even though they may not serve the client wellin the long term. In this way, the client is morelikely to experience the therapist as an ally inthe change process as opposed to someone whooversimplifies or “doesn’t get” the challengesof making changes. Additionally, the therapistalso emphasizes to Mark the importance ofguided activity, highlighting her role as an ex-pert and the importance of careful assessment.She emphasizes the difference between assign-ments derived from a list of pleasurable activi-ties and those that are guided by functionalanalysis, a key aspect of the treatment, towhich the therapist will return many times.

THERAPIST: Those are great observations andare really on target with what I have noticedfor a lot of people as well. What many peo-ple experience is that when they start to acti-vate and engage, they can actually feel worseinitially! The troubling fact about pullingaway or avoiding is that it does providesome short-term relief. But in the long term,it sets up a downward spiral and can keepyou trapped in depression.

MARK: That makes a ton of sense to me. I justdon’t want to do anything. Making a meal

makes me tired. I feel irritated by the soundof silverware scratching on plates. It’s kindof crazy, but I just want to crawl in a hole, toturn out a light in my head and make it all goaway. Then, I end up feeling worse when I dostay in bed. I used to drink, too. I knew itwould make it worse, and I don’t do it muchanymore, but it helped in the moment, eventhough I knew it didn’t really help. I guess Ifelt better temporarily and that was enough.

THERAPIST:Yes, exactly. Avoidance is a per-fectly natural response to depression. Whatunfortunately happens, though, is that youare not in touch with all those things thatcan give you pleasure and a sense of accom-plishment, and you are not engaged in solv-ing the problems that create stress in yourlife.

MARK: I know that would help, but it just allfeels so overwhelming. Just the thought ofit . . .

THERAPIST: Yes, I know. That is where I comein. It’s important to emphasize that thistreatment is not just about me saying youshould “do more” in general. Sometimes Itell people that it’s not the Nike approach totherapy, where I tell you each week to “justdo it.” You have probably received feedbacklike that from other people in your life, andyou may even say something similar to your-self.

MARK: Yeah, guilty as charged.

THERAPIST: My assumption is that if this wereeasy to figure out, you would already havedone it. The reason that you are here is thatit’s not so easy, and that is where my exper-tise comes in. A major part of this treatmentis the idea of guided activation. This meansthat you and I will be working together toidentify specific ways in which you can ex-periment with activation. My expertise liesin figuring out, first, where the places arethat would be the most helpful in increasingyour activation and engagement, and sec-ond, what small and manageable steps youcan take to get started. You can think of meas a coach or consultant to you in the pro-cess of change. We will work together, insmall steps, all along the way. How does thatsound?

MARK: The idea of it sounds good. I guess it’sworth trying.

THERAPIST: I’d like to ask you to read a short





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

pamphlet about this treatment, between nowand the next time that we meet. It will pro-vide you with more information. When wemeet next time, we can talk more about howwe will put the ideas into practice.

With this initial session, the therapist has be-gun to teach the client about the treatmentmodel and is getting the client actively involvedin and on board with the rationale. The thera-pist has oriented the client to their roles intreatment and has given the client his firsthomework assignment (reading the treatmentrationale pamphlet). These critical tasks of thefirst session set the stage for additional discus-sion in Session 2.

Session 2

In Session 2, the therapist carefully followsup on a number of the key orienting tasks,including ensuring that Mark is on boardwith the basic treatment model and explain-ing the structure of the therapy. The therapistattends to these topics in the opening of thesession:

THERAPIST: It’s great to see you today, Mark.

MARK: Thanks. It’s good to be back here.

THERAPIST: That’s great. You know, when I wasthinking about our session last time, I real-ized that there were a couple of points Iwanted to emphasize more. One of the im-portant ones is that this is a very collabora-tive approach to therapy, and one that is alsofairly structured. So each time we meet, wewill start out by setting an agenda for thesession, and we will do this collaboratively.In fact, over time, you will set the agendamore and more, though I may have more tosay about it in the beginning. The idea is thatI’m the expert on how to get over depres-sion, and you are the expert on yourself andyour life, and what things help or don’t help.

MARK: That sounds reasonable to me.

THERAPIST: Great. So in terms of the agenda fortoday, I have a couple of things. I’d like totalk more about the treatment approach andyour reaction, and more about how we putsome of the ideas into practice. Do you haveitems you want to be sure we address today?

MARK: No, that sounds good. I did read thepamphlet, and it really hit home. It was like

they wrote it about me, basically. I thought,“Thank goodness somebody has figured thisout.”

THERAPIST: That’s great. I think one of the coreideas of the model is things happen that tendto trigger depressed mood, and then peopletend to do things, or not do things, thatmake the depression worse. For you, my un-derstanding is that the main trigger was yourdivorce.

MARK: Yeah, I’ve really pulled back on a lot,like not exercising and not doing things withother people or even with my girls. We usedto cook these great dinners together and nowit’s like an effort to get organized to orderpizza. It’s kind of like that everywhere—atwork, too. I’m just managing the minimumand, honestly, a lot of times I’m not even do-ing that.

THERAPIST: I know. It can be very hard to keepdoing the sort of things that will keep youfeeling well. And that is where this therapycomes in. From our session last time andfrom your reading, what is your understand-ing of what we are going to be doing in here,and how I am going to be helpful? If youwere to tell a friend of yours what we weregoing to do in this therapy, what would yousay?

MARK: I guess I would say that we are going topinpoint the activities that give me somepleasure or help me feel like I’m handlingthings well. Then, we will figure out how tohelp me get into the position of being moreinvolved in some of those things.

THERAPIST: Yes, that is a big part of it. Some-times in people’s lives something that is com-pletely beyond their control triggers depres-sion, and then what I call secondary problembehaviors get triggered or made worse.These are the behaviors that involve pullingaway or avoiding, as you were saying, likestopping fun activities with your girls orwithdrawing at work. And in those cases wework on the secondary problem behaviors,and that is the core of the therapy. Othertimes, we also need to address larger prob-lems in your life that may be related to whatmakes you vulnerable to depression. In thosecases, therapy can involve both directly ad-dressing the secondary problem behaviorsand working directly on the problems, afterwe have kind of cleared the path for doing





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

some problem solving by getting you acti-vated and engaged.

MARK: That sounds like it’s probably the casefor me, because I know I had a lot of prob-lems relating to Diane that were part of ourdivorce, and those are not any better.

THERAPIST: Yes, we will talk more as we goalong about what set off the depression foryou. In a global sense, we know now that itwas the divorce. But, as we start followingyour mood and activities day to day, we willsee the ways that your mood has ups anddowns. We will work together and look atthat carefully, asking what set that off, howyou responded to your mood hitting thatpoint, and whether it would help if you triedsomething different.

The therapist has now stated twice that gen-erally a contextual event triggers depression,while earlier acknowledging that several thingscan contribute to vulnerability. This is a subtlebut important point, because clients sometimesbelieve their depression came “out of the blue”or that it is simply “biological” and not modifi-able by behavioral means. By emphasizing anenvironmental antecedent (e.g., a loss of posi-tive reinforcement), the therapist sets up theidea that rather than depression being com-pletely beyond patients’ control, their depres-sive response makes sense, and more impor-tantly, it is possible to make behavioral changesto regain or establish new reinforcers in theirlives. Moreover, the therapist has continued toemphasize the importance of carefully moni-toring and assessing the relationships amongmood, activity, and context as a key part of de-signing effective behavior change plans. Thetherapist then builds on this foundation as shemoves into the other main focus of Session 2—the initiation of activity monitoring. Here, thetherapist explains to Mark why activity moni-toring is important, begins to teach him how tocomplete an Activity Record (see Figure 8.1),and links it directly to some of his recent expe-riences.

THERAPIST: One of the main tools that we usein this therapy is called an Activity Record.This is one example (hands Mark the re-cord); as you can see, it has blocks for eachhour of the day. I’d like you to use this tostart recording your activity and your mood.It’s basically a way to keep track of how you

are spending your time during the day andhow you are feeling. We want to learn whatyou are doing on an hour-by-hour and day-to-day basis. What things in your life helpyou feel better, and what things make youfeel worse? You and I will review these verycarefully together, focusing on how you arespending your time and how you feel. Some-times the Activity Record tells us right awaywhere changes need to be made, and othertimes we have to look at it over a couple ofweeks.

MARK: OK.

THERAPIST: Is there anything you have been do-ing since you started to feel more depressedthat is different from what you normally do?

MARK: Yes, exercising less, watching more TV,and just the amount of time I spend thinkingabout all this. It’s just crazy.

THERAPIST: It’s hard not to do that, but also it’snot helping you very much. And it’s very dif-ficult, which is why you are here. We canstart to figure this out together. It’s great thatyou are already aware of those patterns, andthose are good examples of looking con-cretely at what you are doing. This therapy isabout increasing your awareness of howyour mood is affected subtly from activity toactivity and increasing those that tend to bemore rewarding.

MARK: So, should I write all this down? Doyou really want me to do this every hour?

THERAPIST: Here’s the guideline that I use: Iwant people to record their activity fre-quently enough that they are not relyingheavily on memory. The problem with mem-ory when you are depressed is that yourawareness can be dulled or biased by the de-pression. So you don’t have to do it everyhour. We have to be realistic about the rest ofyour life! But you may want to experimentwith doing it every 3–4 hours. Sometimes,people like to do it at breakfast, lunch, din-ner, and before bed.

MARK: That might work for me.

THERAPIST: Let’s go over what to write down.You put your activity down for each hourblock and then for each hour block you alsoassign a mood rating from 0 to 10. Let’s lookat today as an example. What were you do-ing in the hours before you came here?

MARK: I was at work.





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

THERAPIST: Okay, great. What were you doingat work?

MARK: I was teaching a new employee how touse our computer system. It was really frus-trating because she wasn’t picking it up and Ididn’t have much patience.

THERAPIST: That’s great information to record.Why don’t you write down “working–teaching new employee.” Now, I also wantyou to record your mood on a 0- to 10-pointscale of depression, so let’s see if we can getsome anchors here. What would be 0 moodfor you? This would mean that you feel re-ally good, absolutely no depression or feel-ing down at all. What would be 10? Thiswould be when you feel your absolute worst,the worst you could possibly feel. It might behelpful to think of some activities that are a5 or in between, when you’re not feelingyour best but you’re not feeling particularlybad either. Which activities might be associ-ated with each?

The therapist and Mark then worked to-gether to identify activities that were associatedwith the low, middle, and high ends of thescale. This was completed to provide Markwith anchors to use when completing the moni-toring at home. It should also be noted thattherapists may ask clients to rate mastery andpleasure associated with activities (Beck et al.,1979). Mastery and pleasure may be rated in-stead of or in addition to mood. Often we be-gin by asking clients to record mood ratingsgiven that this is an easier starting place formany clients because it requires less discrimina-tion of subjective experience; moreover, themood rating provides essential informationabout the relationships between specific activi-ties and depression. For some clients, it is help-ful to build on this by teaching them how tohow to distinguish between mastery and plea-sure, and the ways in which both can be helpfulin regulating mood. In the case of rating moodor mastery–pleasure, it is important to reviewcarefully the method and scale we want clientsto use.

THERAPIST: Given this scale, what was yourmood rating for the 2 hours of “working”today?

MARK: Probably a 5.

THERAPIST: That’s exactly it. Now, sometimes

what happens is that people don’t fill it outbecause they think, “I wasn’t doing any-thing.” It’s important to realize that even ifyou are not doing an activity, we want toknow that, too.

MARK: What do you mean?

THERAPIST: Well, when people think “activi-ties,” they often think of things like “goingto the store,” “watching a movie,” “pickingup my child from school.” But, we are con-ceptualizing activity more broadly. It mightbe driving by Diana’s house, or having a sig-nificant phone conversation with someone,or even lying in bed, spending time thinkingabout Diana.

MARK: That would be true on a lot of days.

THERAPIST: Yes, and you can write that down.Those are some of the most importantthings. In some ways, the more detail, thebetter. We want to start noticing subtlechanges. We want to build on those timesthat you feel just a little better, and we wantto figure out what the problem is when youfeel worse.

MARK: I think I got it.

THERAPIST: Great! People usually come awayfrom this thinking that it sounds really sim-plistic. And it does. It sounds simple, but inpractice it is not that simple. It can be diffi-cult to do in the beginning, to really look atall your activities and figure out how yourmood is related to them. It takes skill andhard work on both our parts.

The therapist ended the session by askingMark to review his understanding of the home-work assignment, encouraged him to makecontact by phone if any questions arose, andoffered encouragement about the likelihoodthat she could be helpful to him.

Session 3

As noted earlier, one of the necessary compe-tencies of a BA therapist is the ability to reviewan Activity Record and glean information thatwill help to customize activation and engage-ment strategies. Session 3 focused heavily onreviewing Mark’s Activity Record (see Figure8.2) and using the information collected as aspringboard for more detailed assessment ofkey problem behaviors. Again, the therapist’s





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com


FIGURE 8.2. Sample completed Activity Record (hourly) (assigned on Monday and reviewed on Thurs-day).

Instructions: Record your activity for each hour of the day, and record a mood rating associated witheach activity. Use the scale below with the anchors that you and your therapist develop to guide yourmood rating. Aim to make entries on your Activity Record at least every 3–4 hours each day.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

5-6

6-7 Awake,thinking inbed (9)

7-8

8-9 At work (7)

9-10 Gettingready forwork (8)

10-11 At work (7)

11-12

12-1

1-2

2-3

3-4 Working/teachingemployee (5)

Home (7)

4-5

5-6

6-7 Therapy (5) MakingDinner (6)

7-8 TV (9) TV (9)

8-9

9-10

10-11

11-12

12-1

1-2

2-3

3-4

4-5

Mood Ratings: 0: Feeling really good; not depressed at all (Examples of associated activities:writing; playing with my kids )

5: Intermediate (Examples of associated activities: doing a work task that is onlymoderately interesting but I’m focused and concentrating )

10: Feeling the worst (Examples of associated activities: thinking about how I’ve screwedeverything up )




New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

focus in these early sessions is on increasing ac-tivation in areas that will improve Mark’smood; this work will set the foundation forlater work on avoidance modification andproblem solving.

THERAPIST: Shall we go over your Activity Re-cord?

MARK: Okay. (Hands the therapist the re-cord.)

THERAPIST: Why don’t you walk me through it?(Hands the record back to Mark.)

MARK: I’m not sure if this is what you had inmind. I started the next day after our last ses-sion. I went to work that day, but I was feel-ing so lousy that I left early and came home.I was just kind of fiddling around the houseuntil dinner. I felt really down all day up tothat point; I rated my mood as a 7. I didmake dinner, which was a little better for me.I used to love to cook for Diana and myself,and we would make these big feasts some-times with the girls. Since the divorce,though, sometimes I just grab a bag of chipsor something like that, or on a good night, Imight order a pizza. When I was cooking, Ifelt a little better then, about a 5.

THERAPIST: This is terrific. You did a reallygreat job with this. You completed the re-cord exactly as we talked about—writingdown your activities and also your moodrating—and all of this information is ex-tremely useful. I want to ask you some morequestions about specific parts of the day in aminute, but right now let me just get an over-all sense of things.

Notice how the therapist is careful to rein-force her client’s efforts early in the review pro-cess. Clients are often uncertain about how tocomplete the record, and it is not uncommonfor them to return with partially or improperlycompleted records. In such cases, therapistsmust balance the need to provide correctivefeedback and to reinforce the client’s efforts.Frequent client errors include writing down ac-tivities very globally (e.g., “at work” for 6hours), failing to record mood ratings, or fail-ing to record anything because they did “noth-ing.” In such cases, the therapist should ad-dress these problems in a straightforward andmatter-of-fact manner.

THERAPIST: What happened after you madedinner?

MARK: Well, after dinner, I started watchingTV, and everything kind of tanked fromthere. I sat and watched TV until 2:00 in themorning. I guess it helped in that it kept mymind off of worries about work and just feel-ing lousy about Diana, but I was really de-pressed the whole time. In fact, I rated mymood as a 9.

THERAPIST: That is really important informa-tion. I see that you were also up the nextnight watching TV until 1:00 A.M. Is this trueof a lot of nights for you, or are these twomore like exceptions?

MARK: I wish they were exceptions, but no, it’sbeen more the rule. And then what happensis that I just can’t get up in the morning.Well, I guess I do wake up, but I just lie therein bed. I’ve been getting to work pretty late,and some days I just call in sick.

THERAPIST: So we’ll use this log to pick upthemes of specific activities that can help youfeel good and those that may be contributingto your depression. It seems like there are afew that might be important. I’m thinkingthat the watching TV and going to bed late isone big one, and the other two are cookingand how you are doing at work.

MARK: I think the TV is a really big one.

Notice here that the therapist identified afew broad areas that appear to be related to themaintenance of the client’s depression. The BAtherapist is also alert to disruptions in the cli-ent’s normal routines; in Mark’s case, both eat-ing and sleeping routines appear to have beensignificantly altered. The therapist then workscollaboratively with Mark to target a specificarea for further assessment and problem solv-ing (i.e., nighttime TV watching). At this point,the therapist begins the more explicit process offunctional analysis.

THERAPIST: OK, why don’t we start there? Let’sget clear first about what the problem is, be-cause it doesn’t sound like it’s watching TVin general.

MARK: That’s true. Normally, I would watchsome TV, like I might watch for an hour. But,actually, come to think of it, I was more in-volved in my writing then, too. So, normally, I





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

might watch TV until about 9:00 P.M. andthen turn off the TV and write for anotherhour. Or, if I had the girls, we might watch ashow together and then turn off the TV andread or play a game, or just hang out together,or maybe I’d be on a phone call or something.

THERAPIST: So, this is different for you. Theproblem, then, is that you don’t turn off theTV at 9:00 P.M. and instead watch it for anadditional 4–5 hours.

MARK: Yes, that’s the problem.

THERAPIST: Are you doing this every night ofthe week or just on work nights?

MARK: I hate to admit it, but it’s pretty muchall nights, not always so late, but prettymuch always later than is good for me.

To this point, the therapist has worked suc-cessfully to define the problem in specific andbehavioral terms. With a clear and mutual un-derstanding of the problem, the therapist andclient can begin to consider the contingenciesthat may be maintaining the problem and whatmay be amenable to change.

THERAPIST: We should probably look at whatgets in the way of turning the TV off, since itdoes not seem to have a great effect on yourmood. If you were to turn off the TV at 9:00P.M. now, what do you think would happen?

MARK: I thought about turning it off last night,but I just didn’t want to think about all ofthis stuff.

THERAPIST: By “all this stuff,” do you mean thedivorce and the pressures at work?

MARK: Yes, both of them.

THERAPIST: So, that is what you are activelyavoiding. And the TV helps you to distract?

MARK: Yes, I just don’t have the mental aware-ness now to start writing. I can’t focus on it,and I’m just not interested.

THERAPIST: I think you have the right idea interms of distraction, but the problem is thatyou are distracting yourself with somethingthat doesn’t give you much pleasure and notmuch accomplishment.

MARK: And meanwhile the house is a mess. Ihaven’t paid my bills in months, and . . .

THERAPIST: I think it might be good to help yousolve the problem of watching TV. It might

be simple to solve, but my guess is that thereis more to understand about it.

Notice how easily the client can becomeoverwhelmed and hopeless in response to themyriad problems in his life. The therapist isalert to this possibility during sessions and iscareful to refocus the client on the problem athand. In addition, the therapist also takes akeen interest in the “minutiae” of the client’sday-to-day behavior, particularly if such behav-ior is related to mood. This detailed level of in-terest is critical. Its intent is twofold: First, suchdiscussions guide the choice of activation tar-gets and specific assignments; and second, it isthe intent that such discussions will teach Markto take a similar interest and begin to noticepatterns that are more and less helpful in work-ing his way out of depression.

THERAPIST: Let’s understand better what hap-pens with the TV. Does it come into yourmind, the thought that you might be betteroff if you turned off the TV?

MARK: Typically, I think, “I should go to bed.”But I know that if I go to bed, I’ll just liethere awake anyway, thinking about whatDiana is doing, thinking about how much Iam going to hate being at work the next day.So, then I think I might as well watch TVand distract myself.

THERAPIST: Is that what happens in bed? Youlie there and ruminate about Diana or thingsyou have done or haven’t done at work?

MARK: Pretty much exactly.

In this transcript, the therapist has effectivelyidentified a number of key relationships. Theseinclude the following: (1) nighttime TV watch-ing is associated with deteriorated mood; (2)nighttime TV watching is associated with poorperformance at work; and (3) nighttime TVwatching is potentially maintained via a pro-cess of negative reinforcement in which nega-tive affect (specifically, grief and anxiety) arereduced when the client is watching TV. Thetherapist has done so in a collaborative andnonjudgmental manner, and the client is onboard. At this point, the therapist explicitly ex-amines her hypothesis with Mark about the re-lationship between TV and mood. On the basisof this understanding, they can then considerpossible activation strategies.





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

THERAPIST: I’m wondering if part of what ishappening is that watching TV is helpful inthe short run, because it takes your mindaway from these topics that are connected toa lot of potential sadness and also anxietyabout the future.

MARK: Yeah, that’s true.

THERAPIST: But the tough part is that while itworks in the short run, it’s that same viciouscycle in the long run, because watching TVgives you almost no pleasure and it keepsyou from doing activities that you previouslygot a lot out of, and it sets you up for havingproblems at work.

MARK: Yes, exactly. It’s crazy, I know, but it’ssuch an easy way out when I’m just beatenby the day.

THERAPIST: Absolutely! So we have to take thatinto account when we think about makingany changes here. I’m thinking that youcould try going to bed in spite of that, andwe could work on the ruminating. Or, if youare going to be up, you could do things thatare better than the TV. Which do you leantoward?

The therapist attends to the function (dis-traction) of the problem behavior (TV watch-ing), while engaging in problem solving in avery collaborative manner.

MARK: Probably finding other things, betterthan the TV. I used to go to a book groupone night a week. It was made up of otherwriters and I liked a few of the people a lot,so when I was doing that, I was also doingreading in the evenings, too.

THERAPIST: OK, does reading seem more of away you could start getting back into someof your writing, versus jumping in with writ-ing itself?

MARK: Yes, there is no way I could write now. Iwould just be staring at a blank page, feelinglike crap.

THERAPIST: OK, that makes sense. So whatabout starting with this? One option is thatyou could have a limit for yourself of 9:00P.M. for TV and we could work on identify-ing a book that you could read instead.

MARK: It’s a good idea. It’s more a question ofmy doing it.

It is very important that the therapist notgloss over comments such as Mark’s final state-ment. When clients express doubt about howor whether they will implement an activationstrategy, it is essential to attend to this in detail.Additionally, it is helpful for the therapist to beattentive to statements such as “I’ll just have tomake myself do it,” which generally indicatethat the therapist and client have not suffi-ciently identified the contingencies that controlthe behavior. In our experience, use of sheerwillpower is unlikely to meet with great suc-cess, and suggestions of such signal that furtherassessment is required, as the therapist illus-trates.

THERAPIST: So we need to be sure we are get-ting at the real problem, instead of just say-ing, “Oh, you are going to do this,” andleaving it at that. What kind of reader areyou? Are you someone who can get really in-volved in a book?

MARK: I do get really involved. In fact, I’llthink about the book a lot during the day, ifI’m already into it.

THERAPIST: But getting yourself to do it is hard.

MARK: Yes, it’s getting started on things.

THERAPIST: That is great to know. So, we haveto somehow get you involved in the book sothat when 9:00 P.M. rolls around, you are al-ready involved, so it will be easier to turn offthe TV.

MARK: That would make it easier.

THERAPIST: What if you were to buy a book onthe way back from our session and beginreading it in the café of the bookstore.

MARK: Oh, yeah, that is right on the way back.I can do that.

THERAPIST: Mark, I think the trick with all ofthis is to figure out what is going to help youmove toward the things that will be benefi-cial for your mood. And this is what is reallyhard—getting yourself to go back to thethings that you used to enjoy, when you haveno interest in them right now. When you feelgood, you take it for granted that it’s easy todo things like reading, spending time withfriends or your girls, and even writing. Whenyou don’t feel good, you really notice it. Theproblem is that you’re in this vicious cycleagain. The longer you do not do things, the





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

more badly you feel and the less you want todo. The trick for us is to figure out ways tohelp you start to do some of the things thatwill give you pleasure again.

The therapist acknowledges to the client thatthe new behavior will be hard to initiate be-cause of mood, and that it is necessary to doso anyway. Many times, clients employ an“inside-out” or mood-dependent approach totheir depression; that is, they passively wait fortheir mood to improve before making behav-ioral changes. BA therapists teach clients thatwhen they feel down, they cannot afford towait for a better mood to strike them. The goalis to get active when they feel bad (as hard asthat is). Increasing activation will eventuallyimprove mood, even if not immediately, and itwill interrupt the pattern of secondary prob-lems created by withdrawal and avoidance.Addressing mood-dependent behavior (or talk-ing about an outside-in vs. inside-out ap-proach) is a sensitive point in therapy, in whicha great deal of empathy for the experience offeeling depressed is required. The therapistmust skillfully balance encouragement for ac-tion with validation of the difficulty of activat-ing when depressed. In addition, heavily rein-forcing the client (frequently with the use ofsignificant praise) for any steps taken is essen-tial in supporting the process of change.

MARK: Yeah, I know. A lot of the time I mightknow what I need to do, but I have no ideahow to get myself to do it. I’ve just droppeda lot of stuff, like anything social in the eve-nings. I don’t try to make plans. And, like Isaid, for almost a year I was going to thatwriter’s book group every Thursday. Butthen I said to myself, I’m not writing. Thiswhole divorce is wiping me out. What is thepoint of going? I have nothing to add.” But,it’s true that when I went, I used to get a lotout of it. I’m just not interested now, though.

THERAPIST: Yes, exactly. That’s where you and Iwill work together. I want to come back tothe social connections and the routinesaround writing, but let’s stick with the read-ing and nighttime TV for a bit longer first, ifthat’s OK?

MARK: Yeah, that makes sense.

THERAPIST: Let’s think through this book planagain. Is there anything that might come up

between here and the bookstore that wouldderail that plan?

At this point, the therapist and Mark spendthe remainder of the session discussing particu-lar books he could purchase that would maxi-mize his engagement, and they discuss poten-tial barriers that might arise to derail him fromthe intended plan. They also continued to re-view the Activity Record to identify other keyproblems, including ruminating at work, with-drawing from social networks, and experienc-ing disruptions in routines that previouslybrought him pleasure (e.g., cooking, exercise).In each case, the therapist uses a similarmethod that she used with the problem of TVwatching: defining the problem, identifying theantecedent and consequences, and checkingout hypotheses about how the activity is re-lated to mood with client. In each case, thetherapist also continues to emphasize that sim-ply deciding to “make myself do it” is notlikely to be an effective activation strategy forMark, and that it is essential to tie the activa-tion plan to a clear understanding of the func-tion of the problem behaviors. The therapistemploys a combination of gentle prompting,consistent validation of the difficulty of thetasks and understanding of the temptationof withdrawal and avoidance, and repeateddiscussion of potential barriers to activationplans. Importantly, the therapist also highlightsfor Mark that compliance with the homeworkassignments may not bring immediate relief.

“What will be really good this week is to seewhat effect these things have on your mood.Even if they have just a little bit of a positiveeffect, then we know that we are on the righttrack. And, Mark, they might not have animmediate positive effect on your mood. Itmight be that the act of getting yourself to doit is the success itself, and that you need tokeep doing it for a while before you start tofeel good again. But, it’s my guess that someof this stuff will help your mood a little bit,even in the short run.”

The session concluded with the therapist andMark reviewing the homework assignments,which included purchasing a new book, start-ing to read it in the café, and turning off the TVevery night at 9:00 P.M. and reading. In addi-tion, they agreed that Mark would return a





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

telephone call of an old friend, Mary, who livedin his neighborhood and had been trying tocontact him recently.

Session 4

Mark returned to Session 4 with little improve-ment in the severity of his depression. He re-ported that he had increased his social contact,but that he was not feeling any better. Markalso had delayed the task of purchasing thenew book and continued to watch TV late atnight. The therapist addressed both of theseproblems in a direct, matter-of-fact way.

MARK: It was a really bad weekend. I did callMary and ended up going to this kind ofcocktail party at the community pool thatshe had organized. I was kind of shockedthat I went, but I thought being outsidewould do me good. I was thinking aboutwhat we were talking about, and I thoughtabout how much I used to love swimming. Iwas actually a lifeguard during summers incollege. But I think I felt worse after I went. Isuppose there were moments that were fun,but I was so frustrated by it all. I just spentthe rest of the weekend holed up in myapartment.

THERAPIST: Would that be good to put on theagenda? Doing things that you used to enjoyand not enjoying them?

MARK: Sure.

THERAPIST: And I want to make sure we checkin about how it went with the book versusthe TV, too. Which do you want to talkabout first—calling Mary and the party orthe TV?

MARK: I guess we can do the TV first. I justbought the book today. On Friday, I was atthat party, so I didn’t get home and in beduntil midnight.

THERAPIST: Did you watch TV then?

MARK: No, I do think I was more tired frombeing outside all night, so I just fell asleepwhen I got back.

THERAPIST: And what about Saturday and lastnight?

MARK: It was kind of par for the course. Istayed up late both nights.

Given the importance of attending consis-tently and regularly to the completion of home-

work, here the therapist assesses what in-terfered with Mark’s full completion of the pre-vious assignment.

THERAPIST: I’m glad you bought the book.What got in the way of getting it sooner? AmI recalling correctly that you were going tobuy it on the way back from the session lastweek?

MARK: Yeah, I was, but when I left someonecalled me from work about needing to meet,so I didn’t have as much time as I thought.But I thought I could do it after work, andthen in the evening, I thought, “I’ll get it onthe weekend because I’ll have more time.” Idon’t know.

THERAPIST: If you go back to your leaving thesession last time, when you got the phonecall from work, was there anything else thatderailed the plan?

MARK: No, that was really it. I was still prettyoptimistic about getting the book. It was justthat I didn’t have as much time as I thought Iwould, and I had to get to work.

THERAPIST: OK, that is good to know. So yourplan was to get the book on the weekend,and you just bought it today. On the week-end, did you think about getting it, or did itjust come up again today?

MARK: I did, but I felt so bad after the party Ijust couldn’t get myself to do it.

THERAPIST: It sounds like you were reallydown. Let’s talk about the party in a bit. I’mcurious how it was that you got yourself toget the book today. Are you feeling better, oris it something else?

MARK: I’m not feeling quite as bad, and giventhat I was already out, it was easier to go getthe book. Plus I knew that we were going tomeet and you were probably going to ask meabout it.

THERAPIST: That is so great to know! So onething we know is that I have got to keep fol-lowing up about these things, because ithelps you do them.

MARK: (laughing a little) True, not that I wasenjoying imagining being called to task on it,but it did help, I guess.

THERAPIST: And getting yourself out of thehouse to buy a book this weekend was a lotharder then getting yourself out this morn-ing, since you were already leaving to go to





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

work. Being out already made it easier to ac-complish your task.

MARK: Right. That sort of thing seems to hap-pen a lot lately.

THERAPIST: So one solution would be to notwait for the weekend when you’ve got a spe-cific task to do, because that seems to be aharder time for you to accomplish things.The other thing would be for us to set up asystem of phone check-ins when you are feel-ing particularly down, since it seems to helpto know that we will be following up onthese tasks when we meet. The other issue,though, is to figure out what brought youdown so much this weekend, and what to doabout that.

MARK: I think that is the biggest thing.

THERAPIST: Shall we talk a bit about the partyand the weekend in order to figure out whatis going to help most? How does that sound?And we’ll make sure to come back to the TVand reading plan.

MARK: OK. I would like not to feel as lousy as Iwas feeling.

THERAPIST: Why don’t we take a look at yourActivity Record? (Reviews the record.) Itlooks like your mood ratings were moderateon Thursday and Friday after we met. Then,Friday, at the party and for the rest of theweekend, they were high, 7’s, 8’s, and 9’s,too.

MARK: I’m not sure this is for me, honestly. Ithink I gave it a fair shot, calling Mary, goingto the party. I didn’t want to do either, but Idid. And I felt worse afterwards.

When clients report that they are increasingactivation and their mood is not improving, itis important to assess a number of possibleexplanations. First, therapists may considerwhether the activation assignments were tooambitious and did not incorporate successfulgrading. In such cases, it is important for thera-pists to acknowledge responsibility for this andrecommend assignment based on smaller com-ponents of the task. Second, therapists want toconsider whether the functional analysis wasaccurate. Is it possible that they are activatingthe client in a domain that is unlikely to yieldimprovements in mood? Third, therapists wantto consider whether ruminative thinking is in-terfering with activation. In such cases, clients“physically” engage in the activation assign-

ments, whereas “mentally” they remain disen-gaged from their context and are less likely tohave an opportunity to contact whatever rein-forcement is available. Fourth, it is possiblethat although activation may not immediatelyimprove mood, it may still be “on the righttrack,” because clients are taking active stepstoward solving problems and addressing im-portant life goals.

In Mark’s case, the therapist decided initiallyto pursue the possibility that rumination wasinterfering with activation, based on Mark’scomments in earlier sessions about frequentlyruminating about Diana and their divorce.

THERAPIST: I guess one thing we could exploretogether is what was on your mind duringthe party. When you were standing by thepool talking to other people, or even swim-ming in the water, what was on your mind?

MARK: You know, when I was diving into thewater, I do remember that those were thepleasurable moments of the party. The soundof the water splashing, the coolness, the si-lence under the water, that was all great.That is what I used to love about swimmingtoo. But the other part—I think I was men-tally checking out. I was with a lot of peopleI really like. Mary is great, and her wholefamily was back visiting from the EastCoast. I haven’t seen them in years and I re-ally enjoy all of them. They are great people.But, it didn’t really matter. I just wasn’tthere.

THERAPIST: Were you thinking about Diana oryourself in relation to her?

MARK: Yeah, that was mainly it.

THERAPIST: Were the other folks there convers-ing with you?

MARK: Yes, and I was talking with them. Imean, I could hear the words coming out ofmy mouth, but I was just not there.

THERAPIST: So you have one rating on this re-cord for the party, a 7. But, if we were tobreak these different pieces apart—theswimming, when you were fully engagedwith the activity, and the talking, when yourmind was elsewhere—what would you rateeach?

MARK: The swimming . . . it was good. I guessthat would be a 3, if 0 is feeling good; I meanit didn’t take it all away. But the talking . . .that was terrible, a 9.





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

The therapist has successfully identified theproblem that was interfering with the potentialbenefits of activation. She continues to assessthe nature and scope of the problem.

THERAPIST: I’m trying to figure out if when youare actively engaged in an activity, whichkind of requires some attention to it, arethose the times that are more enjoyable?

MARK: Yeah, that’s true.

THERAPIST: Is this a problem that also interfereswith your mood and accomplishment oftasks at work?

MARK: Yes, exactly. I go into my office and it’slike where does the time go? Hours go byand I haven’t done a damn thing. I’m justwandering over and over things that hap-pened with Diana, what I said, what I couldhave said. It’s awful.

THERAPIST: OK, so we know this is an impor-tant problem to address. It’s interfering withyour enjoyment of times that have the poten-tial to improve your mood, and it’s interfer-ing with managing your job well. Can wespend a little more time on what happened atthe party?

MARK: OK.

THERAPIST: How would you normally be whentalking with Mary’s family, if you were notthinking about all these things? What wouldI see differently in those times than what Imight have observed on Friday?

MARK: I’d be talking to everyone. I wouldn’t befeeling so bad.

THERAPIST: Yes, that is exactly true. What I’mreally curious about is, when you are notfeeling so bad, what would you be doing dif-ferently? Would you be asking them morequestions? Making more eye contact? Re-sponding differently?

MARK: Yeah, all of those things. I’d be more ac-tive in the conversation.

THERAPIST: So you would be more engaged.

MARK: Yes, more engaged. Less of that heavyfeeling; you know, that “this really sucks”feeling.

In the preceding portion of the session, thetherapist has begun to define behaviorally whatMark does in interpersonal interactions whenhe is not depressed. Carefully specifying thesebehaviors is an important step in developing

some possible plans for targeted change in howMark approaches similar situations.

THERAPIST: Do you think that if you couldpractice talking, when you weren’t feelingdown, more like you normally would withthese people that you might feel better?

MARK: I don’t know.

THERAPIST: I think the key is to notice what youdo in response to the ruminating and to seewhether that is helping or not helping yourmood, and then for us to begin to explorewhat you may need to do differently. Itseems that at the party, what you were doingwhen your mood was better, was to be moreengaged.

MARK: It’s true. But, when I’m like this, I don’thave much to say.

THERAPIST: Yes, when you are depressed, youare more quiet and withdrawn.

MARK: Yes, because it’s painful. I see Mary’sparents and I think, “They’ve been marriedfor 30 years. I could have had that with Di-ana.” Then, I start thinking that she is withsomeone else. It just goes downhill fromthere.

THERAPIST: You are absolutely right. There is alot of pain there. And what’s happened isthat in response to that pain, you have nar-rowed activity in your life. So you not onlyfeel the pain of being reminded of that loss,but also there is not a lot else going on inyour life. And even when you are doingthings, you are not as engaged, because youare feeling so much pain. I think we need toget you back to doing the things you did be-fore you had the breakup, and before thetwo of you got together. We need to get youback to your baseline, and once we do that,we can figure out how to get you feeling evenbetter than that.

MARK: It sounds good.

THERAPIST: I know you are thinking this is likepie in the sky, but we can figure out how todo this. The key is to figure out some con-crete and manageable steps to help you en-gage more when you are doing some of theseactivities, like going to the party. You areright. It’s worlds harder to do when you arenot feeling well, but these behaviors arepartly why you enjoyed those occasionsmore in the past. We know that you enjoyed





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

Mary and her family in the past, and weknow that you got a lot of pleasure fromswimming when your mind was fully presentwith the activity. So the trick is not only tocall your friends, like you did so wonderfullywith Mary, but also to go to the gathering,and to get yourself really to interact insteadof just being there at the party. For timeswhen you find yourself withdrawing intoyour thoughts, we need to develop specificstrategies to help you do less of that. Canyou think of anything that would help youdo that?

MARK: I don’t know. I just don’t seem to havemuch to say these days.

THERAPIST: I know it’s hard. There are a varietyof things you could try, such as asking morequestions, and then closely attending to theresponse. Or you could focus on somethingmore specific, such as voice or facial ex-pression, to keep your mind from wander-ing. Sometimes it works just to notice thatyou’ve drifted and to take a deep breath torefocus on your goal in that moment.

MARK: I suppose I could try it. My mind justseems to keep wandering.

THERAPIST: I know. So your job here would beto practice being more vigilant as to whenthat happens, because it will happen. Themore you notice you’re drifting, the moreyou can practice refocusing yourself back onyour friend. Does your mind wander in here?

MARK: I guess a little.

THERAPIST: Why don’t we try it in here? Let’spick something to focus on, and then youcan practice here.

MARK: OK. What do I do?

THERAPIST: I’m going to time us for the next 5minutes and, as we talk, I want you to prac-tice fully engaging in our discussion. Yourmind is going to wander, particularly if weare talking about something that remindsyou of Diana, I would guess. So let’s picksomething you can focus on to bring yourattention back to our conversation. Howabout the sound of my voice, like changes intone, how I articulate words, the pace of myspeech?

MARK: I can try.

THERAPIST: Great. So, let’s talk about some op-tions for social connections that you couldmake this weekend.

The therapist and Mark continued this dis-cussion for the next few minutes, at whichtime, the therapist interrupted their conversa-tion to ask Mark for feedback about his experi-ence.

THERAPIST: What did you notice?

MARK: I don’t know, maybe you are talkingkind of softly.

THERAPIST: How engaged were you with ourdiscussion? Why don’t you give me a rating,with 0 being not engaged at all and 10 beingtotally engaged?

MARK: I guess maybe 7. It wasn’t that hardhere, because I was really focused. I guess Idid start to think about Diana a little whenwe were talking about my calling Mary. I didremind myself to pay attention to your voice,and I guess you just sounded so interested. Itmade it harder for me to wander off in mythoughts when you seemed to be paying somuch attention to what we were talkingabout.

THERAPIST: That was my impression, too, thatyour engagement was generally high, andthat you did appear to refocus your attentiona couple times. That is terrific!

MARK: Yeah, but it was a little strange. I mean,usually people aren’t that focused when theyare just talking about usual stuff.

THERAPIST: That is very true. I might have beenpaying closer attention to what you were do-ing and saying than other folks are in typicalsocial interactions. And this may feel prettyartificial now in general. My guess, though,is that once you get more engaged in socialinteractions, it won’t be necessary to concen-trate so hard. It will just come automaticallyagain.

MARK: That makes sense.

In this way, the therapist generates a strategyto block avoidance (rumination) by substitut-ing a new behavior in the form of attending todirect and immediate experience. Although, inthis case, Mark experimented with directing hisattention to interpersonal stimuli, clients mayalso be directed to experiment with attention toother aspects of sensory stimuli, such as sights,smells, and so forth. The in-session behavioralrehearsal is very important in that it allows theclient to practice and receive direct feedbackfrom the therapist, both of which increase the





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

likelihood of success outside of the session. Thetherapist then returns to the specific task ofreviewing and developing behavioral assign-ments for the next session.

THERAPIST: Let’s go back to your not gettingout all weekend. Do you think going out tobuy the book was too hard? Is there some-thing easier you could’ve done to help youget a little more engaged this weekend?

MARK: I’m not sure. How hard is it to go outand buy a book?

THERAPIST: Very hard, when you’re reallydown. Let’s think about smaller steps. If youcan do a smaller step and get a little rein-forcement for it, then it becomes easier tomove toward your goal.

The therapist and client continue along theselines with graded task assignment. Given thatMark has previously enjoyed socializing, heand the therapist came up with a plan that onthe weekend, he would start by returning somephone calls from friends and inviting Mary forlunch. During lunch, he would focus specifi-cally on attending to their conversation. Thetherapist also raised the possibility of swim-ming as an exercise activity. Mark reportedthat he thought his plate was full with the as-signments they had already developed, andthey decided to table further discussion ofswimming. The therapist then uses the finalmoments of the session to review the home-work, to instill hope in Mark, to validate thedifficulty of change, and to reinforce the basictreatment model.

Session 5

At the outset of the session, Mark reports im-provement in his mood and the therapist in-cludes this as an item on the agenda. Their dis-cussion allows the therapist to emphasize animportant point about maintaining new behav-iors in consistent and regular routines. In thissession, the therapist continues to emphasizethe pattern of social connections and to assessfactors that increase Mark’s vulnerability to ex-acerbated mood when alone.

THERAPIST: Let’s understand in more detailhow it is that you are feeling better?

MARK: I think the reading plan is helping. I fin-ished the book.

THERAPIST: Great! So you probably need an-other book.

MARK: (laughing) I guess that’s true. You don’tthink just the one cured the problem?

THERAPIST: (laughing) Oh, how I wish thatwere the case! Seriously, though, Mark, Ithink that is such an important question.There is a real temptation when you startfeeling a little better to back off from someof the very things that are helping. It makessense, because making these changes re-quires so much effort, I know. But maintain-ing the routines are so important.

MARK: It’s true. I actually think I’ve been doingpretty well with that this week. I’ve beenreaching out more to other people.

THERAPIST: This is fantastic.

MARK: And Mary called me again. So, I guess Ididn’t do what we talked about in terms ofcalling her, but I did ask her about lunchwhen she called. I didn’t really want to, be-cause I was feeling down when she called. Ihad just gotten a letter from the lawyerabout some new money stuff with Diana.But, I did ask Mary, and I took the girls, too.I think they enjoyed it a lot. I did really focuson asking them all a lot of questions duringlunch. I think that helped, too.

THERAPIST: Mark, you have definitely hadmore social contact in the last few days! Youare doing a huge part of this treatment,which is acting in accordance with the goalsand plans that we are setting here, as op-posed to being directed by how you feel inthe moment.

MARK: I tried.

THERAPIST: You did it! You talked about hav-ing lunch with your coworker. Did you dothat?

MARK: I did do that.

THERAPIST: You did a lot! That’s great. OK, Imay be pushing our luck here, but what doyou think about adding swimming to ouragenda?

MARK: I knew you were going to ask aboutthat again.

THERAPIST: (laughing) You know me too well.What’s your thought about it?

MARK: It’s probably a good idea. There isactually a swim lesson that the girls like todo on the weekends, and I could take them





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

and do laps at the same time in the otherpool.

THERAPIST: Fantastic! Do you have them withyou this weekend? Could we schedule thatfor the weekend?

MARK: Yeah, I think that would help.

THERAPIST: Mark, do you think that reconnect-ing with people and some of these activities,like reading, are connected with your im-proved mood?

MARK: Yes, that definitely had a lot to do withit. I am still not sure that we are getting tothe real problem with all of this, but you areright that it does help.

THERAPIST: So we should talk about that, too.Before we move to that, is there anythingelse that you think is contributing to yourpositive mood, or is it mostly having moresocial contact, which you find reinforcing?

MARK: It’s the social contact and trying to dis-tract myself with the reading.

THERAPIST: That is so great! Good reminder,too. Let’s talk some about another book andhow to keep up that schedule.

At this point, the therapist and Mark focuson developing a specific plan for selecting andpurchasing a new book to continue the readingroutine. Next, the therapist returns to Mark’scomments about whether the interventions areaddressing what is most important.

THERAPIST: What you mentioned before aboutthe real problem . . . I’m curious what youmeant.

MARK: I guess I’m still thinking about Diana alot. I think that there is a part of me that hasto let go, yet just isn’t letting go. I am think-ing, just asking myself, “Is there still achance for us? What did I do to screw it allup so badly?” And then I start thinking, “Isthis all I have now—having lunch with peo-ple, reading by myself at night?” You know,the kind of stuff we’ve been focusing on . . . Idon’t know. Is it really going to fix anything?

THERAPIST: Mark, I know it feels like this stuffisn’t really getting at the real problem interms of your thinking about Diana, and Iagree that is really important to talk about.At the same time, I don’t want us to losesight of the fact that this other stuff makes ahuge difference. It’s important for you to re-

connect with ways to buoy up your moodbefore you start to tackle some of the pastproblems and those that still come up withDiana. Also, I think we will find that thereare some similar patterns, so maybe the waysyou have tended to pull away from otherpeople since you’ve been down might havesome connections with what happened withDiana.

MARK: That’s true. I guess they are not totallyseparate.

THERAPIST: Are you saying that it’s time now tostart focusing our time more directly onthose topics?

MARK: I think so. Maybe I’m more aware of itbecause I’m feeling a little better. I guess I’masking more often, “Is this all there is now?”It just seems like a damn lonely life to beleading, if this is it.

The therapist and Mark end the session byreviewing the assignments. In addition, theyagree on a plan to return to Mark’s importantquestions in the next session.

Sessions 6–9

In this next series of sessions, the therapist andMark return to Mark’s question from Session5. In repeated sessions, he reports improve-ments in mood related to making progress onprojects at home, exercising, and becomingmore socially connected in casual and friend-ship circles. These areas of progress are re-flected consistently on his Activity Recordforms, which now specifically target the areasof social engagement, reading, and swimming(see Figure 8.3). (This version of the ActivityRecord can be considered when the activationtargets are clear and well developed, and thedetailed information gained via hour-by-hourmonitoring is not as necessary. It can also beused for clients who have difficulty with themore detailed Activity Record.)

Even with clear areas of improved activationand mood, Mark also reports that his mood isvulnerable to his tendency to ruminate fre-quently about his ex-wife. The therapist andMark begin to explore the potential function ofrumination about his ex-wife. As they did withrespect to both TV watching and ruminationduring social interactions, they develop someinitial hypotheses about the consequences ofMark’s ruminating about his ex-wife.





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

THERAPIST: Is it possible that ruminating mightbe a form of avoidance itself? It’s like yourmind gets stuck in a broken record format.You keep replaying what you did wrong,what you could have done, and one of the ef-fects is that you are actually avoiding thepainful emotions about the loss of the rela-tionship, and maybe also avoiding exploringnew relationships?

MARK: It feels like I can’t stand the loss of it.That’s what I can’t accept—that it is lost. Ikeep thinking maybe there is a way to recap-ture it, even though I know there simply isnot. We can’t even communicate about thekids’ health care without a lawyer.

THERAPIST: So, in a way, ruminating may be away to avoid dealing with grief and sadness.I wonder if part of this comes from what youlearned about how to cope with major lossafter your dad left. It seems like no onetalked about that and you got pretty caughtup in thinking about how you might havebeen responsible. I wonder if it’s hard toknow what to do emotionally right now.

MARK: It’s certainly true about what happenedwhen I was a kid.

THERAPIST: So one possibility we could experi-ment with is taking time specifically to expe-rience the sadness and loss.

MARK: I don’t know. Thinking about her andwhat I’ve lost seems overwhelming. I justwant to be done with it and move on.

THERAPIST: I know. Exactly! The problem isthat ruminating seems to have the effect ofkeeping you from moving on. Instead ofmoving onto other relationships or pursuits

in your life, your mind keeps replaying whathappened and didn’t happen with Diana.

MARK: I just don’t know if I’m ready for otherrelationships.

THERAPIST: So, if you weren’t ruminating asmuch, do you think you might experiencemore fear?

MARK: When I think about getting into an-other relationship. . . . You know, I thinkthat there is actually a person at work who isinterested in dating, but that’s been part ofthe reason that I’ve kind of held back fromdoing things with her. She’s asked me tolunch a couple of times. I just don’t want tobe back in the same place again 2 years fromnow. I can’t take this whole thing again, andI don’t want to subject my kids to it either.

THERAPIST: So, it may be possible that ruminat-ing has the effect of keeping at bay not onlyfeelings of loss about Diana but also fearsabout future loss.

The therapist also emphasize the importanceof continuing with activation plans developedin earlier sessions to maintain adaptive routinesand improve mood. In particular, they high-light the need for consistent attention to socialcontact, exercise, and reading. In addition, thetherapist and Mark begin to discuss his returnto the writers’ group in more detail, beginningto break down that larger task in manageablepieces. Work on these targets forms the major-ity of the middle of the course of treatment. AsMark begins to address feelings of loss more di-rectly and continues his work on social connec-tions, exercise, and limiting TV watching, healso begins to express interest in dating again.


Task Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Reading � � � � �

Reaching outto other people

� � � � �

Swimming � �

Mood 5 5 5 6 8 3 3

FIGURE 8.3. Sample completed Activity Record (daily).




New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

Sessions 10–15

In this section of treatment, the therapist andMark begin to address directly the prospect ofhis developing new intimate relationships in hislife, specifically with a woman at work towhom he is attracted. They explore what isnecessary to approach rather than avoidMark’s fear of starting a new relationship, andthe therapist hypothesizes in particular thatMark’s ruminative style may have functionedto avoid learning from patterns in past rela-tionships. The therapist used the TRAP/TRACacronym as a simple way to help Mark recog-nize the conditions under which he was likelyto avoid (the TRAP), and to then engage inmore adaptive coping behavior to get back on“TRAC.” For example, Mark reported that hewould see the woman at work (trigger) and be-gin to feel nervous (response) and either nottalk with her or restrict his conversation to per-functory work issues (the avoidance pattern).His alternative coping under the same condi-tions involved asking her if she would like tohave coffee. Sessions then focus heavily on ex-amining in detail what he might learn from hisformer marriage that would be instructive infuture relationships. The following dialogueprovides an example of the types of foci thatthese sessions target.

MARK: One of the things that happened a lotwith Diana is I never felt like I was reallypresent with her or the girls. It was like theywere in this little world together and I wasalways on the outside somehow. I oftenthought that I should put myself more in thecenter, like say more of what I thought, but Ijust didn’t. I never did.

THERAPIST: Did that cause conflict with her?

MARK: Yes, absolutely. It was one of things thatshe said when she ended things. Being on theoutside is a big thing for me.

THERAPIST: What does being on the outside in-volve specifically? How would I know if youwere doing that?

MARK: It’s just not being willing to speak upabout things. She always said it was like Iwasn’t really in or out on anything, just kindof on the fence the whole time.

THERAPIST: Can you think of a specific examplewhen that was an issue?

MARK: Well, my mother and brothers never re-

ally liked Diana very much, but I didn’t domuch to stand up for her with them. I justkind of let things unfold. . . .

THERAPIST: So, that might have been a TRAPwith her? Was it a trigger that you thoughtshe wanted something from you in terms ofyour commitment?

MARK: Yes, it was, because I ended up feelingreally overwhelmed by that.

THERAPIST: And the avoidance pattern waswithdrawing.

MARK: I did. I just backed off, and she had tohandle the whole scene with my family.

THERAPIST: So with your coworker, if you wereto take a stand with her now, what wouldthat look like? What would alternative cop-ing be?

MARK: I have no idea.

THERAPIST: Do you think there is a similar trig-ger?

MARK: Maybe, because I think she is wonder-ing what’s up with me? Like am I interestedor not?

THERAPIST: Have you been clear with her aboutbeing interested in dating her?

MARK: Not really. We talk often at work, but Ican’t say that I’ve really said much about it.

THERAPIST: Would you like to ask her out?

MARK: Yes, I guess I would.

THERAPIST: Why don’t we think of some spe-cific things you could say as alternatives towithdrawing and practice with some ofthem?

In these sessions, the therapist and Mark de-fine, in very specific and concrete terms, thetypes of behaviors associated with decreasedsatisfaction and quality in his former marriage.For instance, the therapist’s following questionto Mark is a central question asked repeatedlyover the course of BA: “What does being on theoutside involve specifically? What does it looklike? How would I know if you were doingthat?” The therapist emphasizes identifyingclear, specific, and observable behaviors whenanalyzing behaviors and defining goals. Then,the therapist and Mark work to identify spe-cific strategies that he can use to practice alter-native behaviors in pursuing a future relation-ship. They continue to use the TRAP/TRAC





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

framework to examine situations that arise andMark’s response, and to guide him toward amore engaged approach to intimate interper-sonal relationships. As Mark begins dating,they have ample opportunity to revise and re-fine strategies through activation assignmentsthat target being direct and present in intimateinteractions.

Sessions 16–19

By Session 16, the therapist and Mark agreethat the bulk of the work of understanding andproblem-solving Mark’s depression in terms ofhis unique life context and avoidant responsepatterns that maintain his depression has beencompleted. Mark has been successfully acti-vated both in terms of his secondary problembehaviors (e.g., increased reading, exercise, so-cial contacts, and projects around the house;decreased TV watching). He has also been acti-vated toward solving his primary problem(avoidance of intimacy) via initiating a new re-lationship.

Thus, the final sessions of treatment focusedon reviewing and consolidating primarythemes and methods used in therapy. Spe-cifically, the therapist and Mark identified theimportance of continuing to practice his newskills of blocking rumination by attending toimmediate goals and to his direct and immedi-ate experience, and being more direct and ex-pressive with his new partner. In addition, thetherapist carefully reviewed with Mark theways he had learned to use the fundamentals ofbehavioral activation himself. Together they re-viewed ways that Mark would know when hewas starting to feel depressed or to engage inavoidance response patterns. They also re-viewed specific steps he could take to beginself-monitoring his mood and activities, and toproblem-solve alternative coping behaviors.They also specifically identified a number of al-ternative behaviors that were uniquely helpfulin breaking the vicious cycle of depression,avoidance, and withdrawal. Mark reportedthat he felt well equipped with these tools andthe opportunities he had had to practice themin therapy. He also reported feeling encouragedabout the positive changes he had alreadymade in his life. He ended treatment expressingoptimism about his future and warmly thankedthe therapist for all of their work together.Over time, Mark continued to maintain thegains he made in treatment. He established a

new relationship with a woman, and they be-came engaged over the course of the followingyear. He continued to practice many of theskills he had learned in therapy in the contextof this new relationship, with his children, andwith his coworkers and friends.

Case Summary

The course of treatment with Mark provides anexample of many of the core principles andstrategies of BA. The treatment followed fromcareful and ongoing functional analysis of keyproblems that Mark presented, which in turnallowed the therapist to develop the organizingcase conceptualization. This work was com-pleted in collaboration with Mark during ses-sions and was also a focus of the ongoing clin-ical consultation team meetings, of whichMark’s therapist was a key member. Duringtreatment, the therapist used a range of specificstrategies, including goal setting, self-monitoring, graded task assignment, problemsolving, behavioral rehearsal, and attention toexperience. She also addressed a number of im-portant treatment targets frequently observedin BA, including interpersonal avoidance, ru-mination, and routine disruption. Overall, thetherapist worked as a coach throughout ther-apy, helping Mark to problem-solve specificsteps to overcome patterns of avoidance and toengage in activities. She also taught Mark tounderstand the pattern of antecedents to de-pressed mood and how his responses contrib-uted to either maintaining or improving hismood. She skillfully balanced acknowledgingthe difficulty of change when depressed withemphasizing the importance of action, evenwhen mood is low. She maintained a matter-of-fact, nonjudgmental, problem-solving ap-proach to difficulties that arose during thecourse of Mark’s therapy, and returned regu-larly and persistently to the selected targets ofchange.

CONCLUSION

This chapter provides the conceptual basicsand the how-to specifics that are required touse BA with depressed clients. Evolving fromthe seminal foundation established by the workof Ferster, Lewinsohn, and Beck, BA highlightsthe power of direct and sustained attention tobehavior change. BA aims to help clients be-





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

come active and engaged in their lives in waysthat reduce current depression and help to pre-vent future episodes. BA therapists help de-pressed clients to increase activities that bringgreater reward and to solve important prob-lems. Clients are assisted in approaching im-portant life goals and engaging directly and im-mediately with problematic aspects of theirlives. Both outcome research and other con-verging lines of empirical inquiry suggest thatBA holds promise as an efficacious treatmentfor depression. Future research will examine ingreater detail the process of change in BA andthe ease with which BA can be transported toapplied community settings.

REFERENCES

Addis, M. E., & Carpenter, K. M. (2000). The treatmentrationale in cognitive behavioral therapy: Psychologi-cal mechanisms and clinical guidelines. Cognitiveand Behavioral Practice, 7(2), 147–156.

Addis, M. E., & Martell, C. R. (2004). Overcoming de-pression one step at a time: The new behavioral acti-vation approach to getting your life back. Oakland,CA: New Harbinger.

American Psychiatric Association. (1994). Diagnosticand statistical manual of mental disorders (4th ed.).Washington, DC: Author.

Armento, M. E. A., & Hopko, D. R. (2007). The Envi-ronmental Reward Observation Scale (EROS): De-velopment, validity, and reliability. Behavior Ther-apy, 38, 107–119.

Beck, A.T., Rush, A. J., Shaw, B. F., & Emery, G. (1979).Cognitive therapy of depression. New York: GuilfordPress.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Man-ual for the BDI-II. San Antonio, TX: PsychologicalCorporation.

Bennett-Levy, J., Butler, G., Fennell, M., Hackman, A.,Mueller, M., & Westbrook, D. (2004). Oxford guideto behavioural experiments in cognitive therapy. Ox-ford, UK: Oxford University Press.

Blumenthal, J. A., Babyak, M. A., Moore, K. A.,Craighead, W. E., Herman, S., Khatri, P., et al.(1999). Effects of exercise training on older patientswith major depression. Archives of Internal Medi-cine, 159, 2349–2356.

Borkovec, T. D., Newman, M. G., Pincus, A. L., &Lytle, R. (2002). A component analysis ofcognitive-behavioral therapy for generalized anxietydisorder and the role of interpersonal problems.Journal of Consulting and Clinical Psychology, 70,288–298.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling,K. B., Kohlenberg, R. J., Addis, M., et al. (2006).Randomized trial of behavioral activation, cognitivetherapy, and antidepressant medication in the acute

treatment of adults with major depression. Journal ofConsulting and Clinical Psychology, 74, 658–670.

Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling,K. B., Kohlenberg, R., Gallop, R., et al. (2007).Behavioral activation therapy, cognitive therapy andpharmacotherapy for depression: Relapse preven-tion. Manuscript under review.

Ferster, C. B. (1973). A functional analysis of depres-sion. American Psychologist, 28, 857–870.

Ferster, C. B. (1981). A functional analysis of behaviortherapy. In L. P. Rehm (Ed.), Behavior therapy for de-pression: Present status and future directions(pp. 181–196). New York: Academic Press.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J.B. W. (1997). User’s guide for the Structured ClinicalInterview for DSM-IV Axis I Disorders. Washington,DC: American Psychiatric Press.

First, M. B., Spitzer, R. L., Gibbons, M., Williams, J. B.W., & Benjamin, L. (1996). User’s guide for theStructured Clinical Interview for DSM-IV Axis IIPersonality Disorders (SCID-II). New York:Biometrics Research Department, New York StatePsychiatric Institute.

Foa, E. B., Rothbaum, B. O., & Furr, J. M. (2003). Aug-menting exposure therapy with other CBT proce-dures. Psychiatric Annals, 33, 47–53.

Gloaguen, V., Cottraux, J., Cucherat, M., & Blackburn,I. M. (1998). A meta-analysis of the effects of cogni-tive therapy in depressed patients. Journal of Affec-tive Disorders, 49, 59–72.

Gollwitzer, P. M. (1999). Implementation intentions:Strong effects of simple plans. American Psycholo-gist, 54, 493–503.

Gortner, E. T., Gollan, J. K., Dobson, K. S., & Jacobson,N. S. (1998). Cognitive-behavioral treatment for de-pression: Relapse prevention. Journal of Consultingand Clinical Psychology, 66, 377–384.

Hamilton, M. A. (1960). A rating scale for depression.Journal of Neurology, Neurosurgery, and Psychiatry,23, 56–61.

Hayes, A. M., Castonguay, L. G., & Goldfried, M. R.(1996). Effectiveness of targeting the vulnerabilityfactors of depression in cognitive therapy. Journal ofConsulting and Clinical Psychology, 64(3), 623–627.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999).Acceptance and commitment therapy: An experien-tial approach to behavior change. New York:Guilford Press.

Hopko, D. R., Lejuez, C. W., LePage, J. P., Hopko, S.D., & McNeil, D. W. (2003). A brief behavioral acti-vation treatment for depression: A randomized pilottrial within an inpatient psychiatric hospital. Behav-ior Modification, 27, 458–469.

Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M.E., Koerner, K., Gollan, J. K., et al. (1996). A compo-nent analysis of cognitive-behavioral treatment fordepression. Journal of Consulting and Clinical Psy-chology, 64, 295–304.

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001).Behavioral activation treatment for depression: Re-





New York, NY 10001 212-431-9800 800-365-7006

www.guilford.com

behavioral activation for depression 343 · other people have stressful things in their lives and...

Documents