Monday Matters: A mini guide to using Behavioural Activation as a treatment for depression

In last week’s blog post, I mentioned that my support worker and I have been using a technique called Behavioural Activation (B.A.) as a practical treatment for my depression and anxiety. Today, I thought I’d share an introduction to how B.A. works, ways in which it can help ease depression and anxiety and some tips on how to get the most out of using the method.

What is Behavioural Activation?

Behavioural Activation is an effective and pro-active treatment for depression which can be used in addition to medication and CBT techniques. Research shows that when individuals are struggling with depression their activity levels reduce, leading to less enjoyment and achievement and feelings of lethargy and poor motivation so that even small tasks and activities become hard work. This then becomes a vicious cycle of inactivity – depression and anxiety – inactivity and so on leading to us feeling worse.

Additionally, a person may engage in unhelpful behaviours such as turning to drugs or alcohol, staying in bed late into the day, withdrawing from social situations or sitting ruminating about things.

Behavioural Activation (B.A.) aims to break the above cycle by increasing pleasurable and positive activity each week with a view to improving mood and decreasing feelings of anxiety, including any negative thoughts you might be having such as “I’m a useless wife/husband/partner”, “I can’t do this anymore”, “I’m never going to get better” etc.

Although Behavioural Activation is a relatively simple idea and can be used as a self- help strategy, I think it is best done with a therapist or support worker so that they can guide you through the process and provide encouragement along the way. They can also look at the particular difficulties you’re having and help you to put things in place to make positive steps towards tackling them.

Establishing a baseline – the first step of Behavioural Activation

Once you understand the principles behind B.A. therapy the first step in the process is to monitor your current activities throughout the week and how they affect your mood. This can either be done using an activity monitoring sheet, examples of which can be found online, or by simply making a list of what you do each hour of the day and scoring your mood out of 10 each time, 0 representing feeling very depressed and 10 representing feeling really good. This should help you to clearly see the relationship between your activity levels and your mood. You could also try listing which of your activities made you feel good and which made you feel bad, for example going for a walk in the park made me feel good, sitting and worrying that I’ll never get better made me feel bad.

Using a ‘Weekly Schedule’ sheet to make plans – the next step in the process

Once you’ve established what you are currently doing, it’s time to make some small improvements. Each week, you work on creating a schedule which should include routine plans such as having breakfast, going food shopping, pleasurable activities such as playing cards, watching TV, doing something creative etc and necessary things that need doing e.g. paying your car tax.

You should also try to include activities which you already do that make you feel better such as getting dressed, brushing your hair, going for a daily walk etc. So, for example, even though I didn’t feel like doing my yoga each day, I did it anyway as it helps to calm me and I feel good after doing it.

What you write in the boxes depends on your current difficulties. For example, if you are struggling to get out of bed you might write in the first box ‘Up by 9.00am’, ‘Have breakfast’ and ‘Get ready’ (dressed, teeth brushed and face washed). If you’re currently not doing any household chores, you might add laundry related activities to your list. This can be broken down into small steps e.g. ‘Load the washing machine’, ‘hang out clothes’ and ‘Bring in washing’.

You should also try to think of activities which are important to you, for example spending time in nature, being creative, quality time with family or friends, eating a balanced diet etc. These are related to your core values and you might want to talk to a support worker or therapist to establish what you want from life so you can set some goals for the future. Although your depression is likely to lead you to believe that things will never get better and you will never again feel a sense of pleasure or achievement, try to think of your situation as temporary and know that things will improve in time (I know this is much easier said than done though).

Using your weekly schedule to good effect

Your weekly schedule is your plan for the week and is a guide for what you hope to achieve. It should be referred to throughout the day and will help you see what you have planned. It’s also a place to record your achievement and enjoyment levels (out of 10) so you can evaluate the effect B.A. is having on your mood. You might also like to spend time each evening reflecting on your day – you could even do a little journalling too. If you find your enthusiasm waning at any time, remind yourself why you’re using Behavioural Activation and think about the positives so far.

Tips on using Behavioural Activation to treat depression

Start small When I first started planning out my week according to the principles of B.A., I would identify one activity for in the morning, one for in the afternoon and another for in the evening. This would mainly include relatively simple and mindful activities which helped to distract my anxious and negative thoughts and improve my mood a little. So, for example, in the first week I would have breakfast, get dressed and straighten my hair in the morning, go for a walk in the park in the afternoon and then play cards, do some of my jigsaw or watch TV in the evening. By week 5, I was doing several activities in the morning, afternoon and evening and setting more difficult goals for myself. However, we always made sure I had some time for pleasurable and relaxing activities each week such as reading my book in bed two mornings a week (after having a good breakfast and brushing my teeth and washing my face).

Break down activities into steps When you’re feeling depressed, it’s common to lack the motivation to do even basic things. For this reason, it’s helpful to break down activities into small steps which feel more achievable. So, for example, ages ago I bought a cheap set of gouache paints and really wanted to have a go at using them. Rather than creating a full page art piece, I set myself the simpler task of painting some stems and leaves. For the first step, I experimented with creating different shades of green by mixing varying amounts of blue and yellow. Then I introduced small amounts of other colours of paint to explore what happened. I also added white to some of the mixture to make lighter shades. After that, I tried painting samples onto a small strip of watercolour paper to see if I had the consistency of the paint correct as I knew that gouache is quite a bit thicker than watercolour which I’ve used many times before. This was all I did on the first day. I returned to my paint samples a few days later and decided to have a go at some stems and leaves. I spent time looking online at different stem and leaf shape and patterns and then had a go at creating them using a small selection of brushes. By breaking down my art project, I avoided feeling overwhelmed. I also did the same for housework tasks e.g. rather than cleaning the whole kitchen, I started by just cleaning and polishing the sink area.

Routine, Pleasurable and Necessary Try to create a balance of activities on your plan so that you engage in a range of pleasurable and achievement related activities each week. So, for example, you might do some watercolouring on Monday morning because you know that you have enjoyed painting in the past. This would be a pleasurable activity (even if you believe that you won’t enjoy doing it). On Tuesday morning, you might put one load of washing in the machine and then hang it out in the sunshine when it’s finished. This would be a routine task (something that needs doing regularly) and is likely give you a sense of achievement. On Wednesday afternoon, you might plan to get a few necessary tasks out of the way such as renewing your car insurance, replacing a lightbulb or replying to an email or text message from someone.

Evaluate how your week has gone During my weekly support sessions, Nichola would ask me how my week had been and part of this involved talking through how I’d got on with my B.A. plans. This gave me the chance to share my achievements but was also an opportunity to identify any problems I’d had, if I’d found solutions myself or if I needed help to find a way forward. For example, one week, I’d got really upset because my dressing table in the bedroom was thick with dust and I felt ashamed at how bad it was. I only cleaned this one piece of furniture instead of the whole of our bedroom as I became really overwhelmed. We discussed that sometimes a task may need modifying or simplifying to make it easier and that I may need to try to be kinder to myself / show more self compassion etc.

Reward yourself regularly As well as going easy on yourself, it’s also a good idea to spend time recognising your achievements and reward yourself for progress made. As well as doing this with Nichola once a week, my husband talks with me about how my day had been and what I’ve achieved. Also, every Friday afternoon, we go to my favourite café for a coffee and cake as a well deserved treat. This has become a part of our weekly routine which will have carried on even though I’m now feeling much better and it’s not so hard to get things done.

Enlist the support of others If you find it difficult to motivate yourself to do the activities on your weekly schedule, it can be helpful to ask others for support. This could be a family member or friend who regularly checks in with you to see how you’re getting on and provides gentle encouragement. They might also help you with a particular task e.g. preparing a meal, filling in a form or tidying a space in your home.

Final words…

Although Behavioural Activation on its own isn’t a cure for depression, it can be a really useful coping mechanism and a helpful treatment for lifting your mood. Hopefully, in time, you will find that you start to enjoy some of the activities on your plan or feel a sense of achievement when you’ve completed tasks that you’ve probably been avoiding. As you continue to schedule in activities and complete them successfully, you’ll likely be motivated to do more. Remember, though, that there may be days along the way where you don’t feel so good and some of your tasks might not get done. This is okay and perfectly normal – just go easy on yourself and celebrate what you did achieve. Even a small number of activities done each day can have a big impact on your mood.

If you have any questions about Behavioural Activation, feel free to drop them in the comments and hopefully I’ll be able to answer them or direct you to an online resource which might help. Also, if you would like a copy of my Weekly Schedule, I would be more than happy to share it – just get in touch using the email address in the ‘Contact me’ section of my blog.