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Behavioural activation for Male post-natal depression

Just do it!

Behavioural activation (BA) is an integral part of CBT treatment for depression and here I intend to introduce what it is and why it is so effective.

Behavioural activation for depression focuses on improving mood by encouraging the depressed person to understand the relationship between behaviour and depressed mood.  Once we understand how you “do” your depression behaviourally, then we can start to change your behaviour to bring about positive change.

As this guide aims to give you the tools and skills to manage your own depression symptoms in as easily accessible way as possible, I’m going to detail much of the science behind Behavioural activation for depression elsewhere on the site.  This allows us to get right into how to apply behavioural activation straight away.

Black and White photo of a man carrying a bike over rocks

Nb: And for those of you who want an even quicker start you can download the quickstart sheet here.

Depression and Behaviour – What’s the connection?

Depression is an enigma of our time.  When people are depressed, they have a tendency to look inside for the reasons as to why they are depressed.  “Why can’t I do better?”, “Why do I always let people down?”  We sometimes believe that, if only we could find the reason why we are depressed, then we can think our way out of it and make ourselves feel better.

It is common within depression for an individual to experience changes in behaviour and reductions in activity levels. You may be experiencing this yourself at the moment. You know that you could go out for that walk or make that call to your family but nothing seems to be motivating you to do it. You procrastinate or avoid doing what was previously a simple, often enjoyable task. Why does this happen?  I explain more about this in the following video:

The diagram on the right illustrates this further.

We can see here how being exposed to difficult life events leads to difficult negative emotions such as sadness, anger or anxiety. We will explore exactly how this process occurs in more detail when we start to look at the role of cognition, but for now it is important to stress that this is something that we all share – when life is difficult, we experience emotional distress.

Just like with physical pain, if I am exposed to something which causes me distress, it is a natural response for me to want to move away from it. For instance, if I put my hand on a hot stove, my natural reaction is to pull away. If I didn’t, then I would experience even greater pain and cause physical damage to my hand. Viewed in this light, pain serves the purpose of keeping me safe and preventing further injury. This is also true of emotional pain.

Diagram showing the relationship between depression and activity, underpinning behavioural activation,

Why do we feel depressed anyway?

Evolutionary theories relating to depression suggest that negative emotions developed to serve the purpose of providing us with a signal to reduce further exposure to stressful life events. Just like with the hot stove, the sadness I feel when exposed to a particular stressor can be quickly relieved by pulling away from it. Of course, this is fine if it is just the one stressful event which I have to deal with, however, as you probably know firsthand, this is not always the case.

As we have already highlighted, having a new baby on the scene can come with a huge amount of challenges, many of which can carry some degree of emotional distress. Having my sleep disturbed for the 3rd time tonight may make me feel the emotion of frustration. Being criticised for putting a nappy on wrong might make me feel sadness. Being pushed out of the way while the mother-in-law barges through may make me feel envy. None of these are pleasant emotions and it is a natural response for us to pull away and avoid the cause of the distress. As a short term solution this may work, however if the use of avoidance is our primary strategy to dealing with the multiple challenges which come with being a new dad, we may start to find ourselves avoiding causes more and more. I start sleeping on the couch to avoid the night feeds. I make excuses to avoid changing nappies. I lock myself away and pretend to work when my mother-in-law is coming to visit.

As a consequence of this spiral of avoidance, I now find myself doing less and less, isolating myself further and missing out on the potential positives of being a new dad. As I isolate myself, I find myself with more time to mull over and brood upon why I’m not able to cope with these challenges, making myself feel worse in the process. Without realising that my avoidance and reduced activity levels are actually feeding my depression, I’m already living a life of making excuses, isolating myself and minimising opportunities to experience life events which might actually lift my mood. As depression progresses, I may do less of the basic activities which I once found it easy to take care of. Getting showered, putting on clean clothes, staying in contact with family or friends are all typical behaviours which can fall by the wayside as a consequence of depression.

How to do Behavioural activation for Depression

So what do we do about this? Well, as the name might suggest, behavioural activation is the technique of activating the depressed individual to engage in activities which have fallen by the wayside. This is how we do it:

Step 1 – Setting a Baseline – What are your activity levels like this week?

The graphic below displays one of the main tools in behavioural activation for depression: The activity diary. You can download your own copy here.

CBT Activity Diary for Behavioural Activation for Depression

A behaviour diary is used within CBT to both record current levels of activity and to schedule future activities which may be beneficial to alleviating your depression. Currently, we are going to use it to fulfil two functions:

1. To develop a baseline measurement of your current activity levels prior to engaging in any behavioural activation.

2. To identify specific activities which lift your mood.

HOW TO USE THE BEHAVIOUR DIARY:

Take a look at the diary and you’ll see how it breaks down into hourly sections, from 07:00 am until 12:00 am, for each of the 7 days of the week. What I’d like you to do is to record each activity you engage in for a one week period. By “activity”, I mean every behaviour you find yourself doing, from eating, walking and watching T.V. to staring out of the window, playing squash and having sex. Take a look at this example…

Picture showing an example of a completed activity diary for use in behavioural activation for depression

After a week of completing the diary, take a look at it. What do you notice? Are there any patterns of inactivity which emerge. Are there any situations or people which you avoid more than you realised. Did you do anything that you enjoyed? Often when people complete the baseline activity diary, they can be shocked by the patterns of inactivity, avoidance or lack of routine which have become a part of their lives. But I don’t want you to be put off by this. This is just a baseline, a starting point. Take this diary and put it somewhere safe for now as it will be a useful comparison as we are on our way to recovery.

Step 2

Take a fresh activity diary and, again for one week, start to record the activities which you engage in on an hourly basis. This time however, we are going to add a little bit more information. For each of the activities, I would like you to answer the following two questions:

• How much pleasure did I feel whilst doing this activity?

• How much achievement did I feel whilst doing this activity?

What do I mean by pleasure? Literally any positive feelings at all, even if it was the slightest emotional lift for just a few seconds. A walk in the park, a hug off your partner or playing with your child may give you more pleasure than, say, staying in bed for the day, or staring out of the window. I’d like you to rate pleasure on your diary on a 0 to 8 scale, with 8 representing the most pleasure you could possibly have from an activity, 0 representing none at all.

What do I mean by achievement? This means any sense of mastery or pride in completing an activity. Based upon experience, this section often requires some degree of clarification. I’ve had clients return to me having scored some activities reasonably high in terms of pleasure, but failing to score anything in terms of achievement. Upon discussion regarding this, many assume that basic tasks such as shaving, preparing a meal or getting the baby dressed are “things I should be doing anyway” and as such do not merit any sense of achievement. This is an assumption which I challenge straightaway. The client is evaluating their achievements based upon how they would expect to be if they didn’t have depression, when the reality of the situation is that they do. The very fact that the individual is doing something which they would typically be avoiding due to their depression confers some degree of achievement, and this is what I would like you to remember when you are rating your activities for achievement. Rate them as you are TODAY, not as you think you should be. Again, rate the level of achievement experienced from each activity on the same 0 to 8 scale. Here’s an example of a completed dairy with A (achievement) and P (pleasure) ratings included.

Example of completed activity diary with Achievement and Pleasure ratings in behavioural activation for depression

So now we should have two full weeks worth of data relating to what your activity levels are currently like, and how much pleasure and achievement you are taking from them. All sorts of useful information can come out of using the diary. For instance, we can see the areas of our life which actually do give us, even if just for a short time, an increase in positive experience. Likewise, we can also identify the activities which contribute very little to our sense of achievement or pleasure, such as the four hours of watching T.V. each night we might engage in. We can also see patterns in our behaviour more clearly. Sometimes people will notice that they are sleeping during the daytime more frequently than they thought, or notice that they are drinking alcohol throughout the week. The data that we get from using the baseline behaviour diary can be enlightening, useful and at times surprising, but if you use it as I’ve described, then the foundations of behavioural activation are set and we can progress to the next stage of your recovery. Next, we are going to start activating – identifying the behaviours which give us the most positive uplift, or which tie in with our values, and schedule more of them in our lives. Click here for Getting activated, part two.

Activity scheduling

Pleasurable activities

Taking a look at your completed diary, are there any activities which you have rated more highly in terms of pleasure than others? Even just a little? If there are, then we have got evidence to support the idea that doing more of this stuff will make you feel more pleasure. Take a blank activity diary and we are going to schedule some activities for the next week based upon this. Take the first activity that you have rated more highly than others and write it down on the activity diary at a time when you will be able to do it. For instance, if I rated the activity of “taking the baby to the park” with a pleasure score of 6, then if I schedule it for another time in the next week, or possibly even twice over the next week, then it is likely that I will experience a similar degree of uplift. Have a go…

When you have scheduled the one activity, I’d like you to repeat the process with another activity that you have rated highly for pleasure. Just write it down on the diary at a date and time when you feel you are going to be able to complete it.

Achievement activities

Now we are going to take a look at the achievement based activities. Again, initially identify one or two activities which have scored more highly than others in terms of achievement. You may have completed a task in work or had a conversation with your partner which you may have been previously avoiding. Whatever it was, again schedule the same or a very similar activity into the diary for the next week.

As we are just getting started with behavioural activation, we’re not going to overload the diary with tasks for the next week. We just want to ensure that the tasks we have set ourselves are going to be manageable, and to set ourselves up for success. Regular, small successes are the key to challenging low mood.

Value based activities

Remember the values assessment? If you have completed it, I’d like you now to take just one of the values (e.g., Father, Partner, family, etc.) and consider just one activity which might support this value. For instance, if I choose the “father” value, an activity related to this might be “Play with the baby for one hour.” Once you have chosen an activity, again write this down into the diary. Other examples of activities associated with each of the Values assessment dimensions might be:

List of value based activities identified in CBT Behavioural Activation for Depression

The idea here is to begin to include activities which fit in with our values, so we are starting to live our life as we want it to be, rather than how depression makes us feel it is.

Implementing the diary

Now you should have a diary which looks something like this:

You’ll notice that it’s not overloaded with activities. The idea here is that we are building up our activity levels gradually, and setting ourselves up for success. If we put too many items on the diary to start with, then it may seem too big a task for us, and we may give up and become frustrated with ourselves if we struggle to complete it. Too few, and we won’t experience the sense of pleasure, achievement and activation which we are after. There will be plenty of time to add to the diary as your recovery progresses so, for now, aim to be realistic and kind to yourself.

At the start of week three, now is the time to implement the diary. When the day and time arrives for when you have scheduled your activity, stick to the plan and act the activity out. Once you have acted the activity out, in the same way that you have done before, rate the activity in terms of achievement and pleasure. This gives us evidence relating to whether the activity works for us in lifting our mood. It’s really important to remember here to stick to the plan, not to how you feel. As we have talked about before, depression is typically characterised by a reduction or avoidance of activities and the urge on some days to not bother with implementing activities may be particularly strong. We need you to, as much as possible, to stick to the plan. This is another reason as to why we don’t overload the diary with activities to begin with – Small, realistic successes are the path to recovery.

In addition to carrying out the scheduled tasks, I’d like you to, just as before, record all of the other activities which you engage in on an hourly basis and rate them for achievement and pleasure. Again, we are interested in identifying further activities which elevate mood, and in any patterns of avoidance.

Reviewing your progress

Once you have implemented your activity diary, it’s time to spend a few minutes reviewing how it went. Were you able to complete all of the tasks that you had scheduled? What ratings did you give them? Was there anything that you would have done differently? What effect did the activities have upon your mood? What do we need to do for the next week?

It is important to approach this review stage with an as open, non-judgemental attitude as possible. If you haven’t quite managed to complete all of the activities which you scheduled, then maybe you need to break that particular activity down into smaller, more achievable chunks and schedule them first. Be kind to yourself. This is an ongoing process and can take time. By allowing yourself the space to move forward, without critical self-judgement for minor setbacks, you are going to be on your way to recovery.

Repeat

Now that we have got the ball rolling with Behavioural Activation, we need to keep it rolling. Even though this site will cover other CBT techniques to reduce depression, Behavioural Activation has been shown in clinical studies to be an effective treatment for depression on its own. Some studies even suggest that it is the sole agent of change in CBT for depression. For this reason, we need to stick with it.

After week 3 of scheduling and recording activities, I would like to you to repeat the process on a weekly basis. As it becomes a habit, you will notice your mood start to lift. You will be finding and engaging in achievement and pleasure based activities and living your life in accordance with your own Values. Keep going with this as you explore the other CBT techniques covered in this site. Record your progress and use the phq-9 self report measure to assess your depression symptoms on a weekly basis. Next up, Cognitive restructuring