Posted in Bipolar disorder, depression, depression management, lifestyle, mental health, Planning and journaling, wellbeing, wellness

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.

Source: NHS Greater Manchester Mental Health

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.

My modified B.A. weekly schedule sheet created in MS Word

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.

Posted in CBT, depression, lifestyle, mental health, Planning and journaling, psychology, wellbeing

Monday Matters: Negative self-talk – its impact on you and 3 ways to challenge and reframe it

For today’s Monday Matters post I want to discuss something which I’m currently really struggling with, and that is negative self-talk. I’ve been taught various strategies in different therapy sessions throughout the years but applying them when you’re really struggling is easier said than done. Also, during periods of better mood, the techniques tend to be forgotten about as the amount of negativity is much less. So, here’s some examples of different types of negative self talk, an outline of how it damages us mentally and three key ways to challenge and reframe it.

What is negative self talk?

Before you can begin to challenge your negative self-talk you need to know exactly what it is so you can label it as such as soon as it pops into your head or out of your mouth. Basically, we have lots of thoughts running through our minds all of the time such as ‘I wonder if there’s anything good on TV tonight?’, ‘I haven’t done any watercolouring this week, perhaps I’ll have a go at some tomorrow’ or ‘I feel a bit rough today so I’m going to take it easy’. These kinds of self-talk and reflection are perfectly normal and help you to make decisions and get on with things in your life. However, when the self-talk becomes harsh and self critical, such as ‘I can’t believe I did that, I’m such as idiot’, this is when it becomes a problem and can be really damaging in all kinds of ways.

The main forms of negative self-talk (AKA cognitive distortions)

The following are some of the main forms of negative self-talk. In psychology, they’re known as cognitive distortions because they’re inaccurate, exaggerated, irrational and negatively biased.

Overgeneralisation – this is where we draw conclusions about things in life or the future based on things that have happened (often once) in the past e.g. all men are liars, we’re bound to get stuck in traffic, bad things always happen to me, I’ll never be able to do that, I always fail.

Catastrophising – very closely related to the above, this is where we imagine and believe the worst will happen and completely blow things out of all proportion, for example, during a period of depression, saying that you will never get better and will spend the rest of your life miserable, or following the end of a romantic relationship, stating that you’re unlovable and will never find anyone else.

Mental filter – this is when we experience positive and negative things but only focus on the bad stuff and filter out anything good. So, for example you might have had a day out at the park, enjoyed a picnic in the sunshine, strolled around the lake, feed the ducks and swans and admired the cute, fluffy little cygnets before getting an ice cream from the café. But, on return home, you might say that you had an awful time because you were stupid enough to drip ice cream on your t-shirt and that you got burnt because you failed to re-apply your sunscreen.

Predicting the future (AKA fortune telling) -this is where we predict what is going to happen based on little or no evidence, for example, we might say things like: ‘I just know I’m not going to get the job’, ‘I’m not going to the party because I’ll have an awful time’.

Mind reading – here, you assume what others are thinking, often in a negative way. So, for example, you might decide that your friend hates your clothes because she didn’t say how nice your new dress looked, or you might conclude that your husband is sick of you because you keep getting upset all the time.

Black and white thinking – this one involves thinking in extremes rather than anything in-between or in a ‘shade of grey’. It commonly involves the use of the words ‘always’ or ‘never’. Some examples that I’ve said recently are: ‘I always mess things up’, ‘I’ll never get better’ and ‘I’m a complete mess’.

Labelling – these are things that you say about yourself either in your head or out loud which are wholly negative and unhelpful e.g. ‘I’m a fat pig’, ‘I’m useless’, ‘I’m such a failure’ etc.

Shoulds and muststhis involves putting undue pressure on yourself and creating unreasonable expectations which become impossible to keep. For example, you might say ‘I should be a better wife’, ‘I must tidy up all of this mess’, ‘I should exercise more’, I must make sure I’m on time for my appointment’. Using ‘I need to…’ isn’t particularly helpful either e.g. ‘I need to lose weight’, ‘I need to be a better mum’, I need to get that work done’. I’ve written an in depth blog post on this previously as it’s something we covered in my compassion group classes.

The consequences of a tendency towards negative self-talk

As well as causing high levels of stress for both the individual and their close family and friends, negative self-talk has a number of negative consequences including:

  • lack of self belief
  • poor levels of resilience
  • diminished ability to make positive changes in your life
  • reduced self-confidence
  • decreased motivation
  • feelings of worthlessness
  • feelings of hopelessness
  • likelihood of depression and anxiety being exacerbated

Personally, I find that negative self-talk goes hand-in-hand with depression and feelings of anxiety which only serves to make things worse.

3 ways to tackle your negative self-talk

In order to remedy our tendency to negative self-talk we need to recognise when we’re involved in it and actively challenge our words. Here are three ideas on how to do this:

Recognise it, write it down and challenge it

There are a number of psychological studies that have looked into developing awareness of self-talk and the key findings suggest that those individuals who wrote down their own personal examples in some form of log book showed greater insight into the specific content of their self-talk and the consequences of its used. They were also able to start challenging their initial thoughts in order to create more balanced conclusions.

Recognising and challenging your self-talk takes time and commitment but is really worthwhile doing. The following example is my own and I hope, by sharing it, you can see how the process works (you may need to click and enlarge it to see properly). When challenging the evidence, I find it helpful to think about what a good friend or my lovely husband might say in response to what I said.

Take it to court

This is a great technique, which I used in my chart above and feel is really helpful for cross examining your self talk. It commonly used in CBT (Cognitive Behavioural Therapy) and involves metaphorically take the thought or belief to court and place it in the dock. You then find evidence for and against the thought or belief, considering the factual evidence and not opinions. Working for the defence, you try to prove that the accused (your thought or belief) is truthful and correct by providing evidence that shows that your thought or belief is 100% totally true. You can see examples in column 4 of my chart. Then, working for the prosecution, you look for evidence that this thought or belief is not true 100% of the time. For this, you need to select good quality evidence that would hold up in court. Finally, the judge summarises all of the evidence and composes a final statement which is realistic, rational and balanced. This should then help you to see alternative ways of thinking and enable you to undermine your extreme and unhelpful though. You can find worksheets to go with this technique at Getselfhelp.co.uk.

Find more positive alternatives

When you catch yourself saying negative things, try to come up with more positive alternatives or different ways of looking at the situation. Again, think about what a good friend or your partner would say to counteract your thought or belief. Here are some examples which might help:

Negative self-talkPositive self-talk
I hate feeling like thisIt’s okay to feel like this, my feelings are valid
I’m never going to get betterThis is temporary and I have the ability to get through it. I’m taking things one step at a time.
I hate my bodyI’m grateful for everything my body can do, I’m healthy and strong and my body is beautiful.
My life is awfulThere are so many good things in my life right now.
I’m getting everything wrongEveryone make mistakes and we all have days that are better than others.
I need to do some exerciseI would like to do a little more exercise so I can feel more toned.
I can’t do itIt’s going to be hard work but I can do it
I’m so stupidI made a mistake, so what, everyone makes them!

Final thoughts

You might not need to complete these exercises all of the time but when you find yourself dealing with feelings associated with anger, depression or anxiety, try to make time to stop and become more aware of your thoughts. Then you can start to reflect on them, challenge your views and find alternative ways of looking at things. Hopefully, after developing the skills associated with thought investigation and thought challenging, you’ll find it easier to put the ideas into practice and conquer your negative self-talk and start being nicer towards yourself.

Thanks for reading and good luck!