Behavioral Activation Techniques for Depression in a variety of settings: Groups, Peer-to-Peer and Non-Clinical Settings

1
Behavioral Activation Techniques for Depression
in a variety of settings Groups, Peer-to-Peer
and Non-Clinical Settings

• by
• Susan L. Bandy, M.A., QMHP, LPC
• Chestnut Health Systems
• Granite City, Illinois

2
Order of Topics

• Group Dynamics
• Therapeutic Factors
• Group Therapy Basics
• Problem Severity
• Behavioral Activation Techniques Definition
• Good Research Model

3
Order of Topics

• The Two Manuals Original Form Group Form
• Treatment Techniques the Forms
• Assessments
• Uses of the Forms
• Overview of Tasks to be Accomplished Within the
  Group
• Session by Session Outline

4
Universal Group Dynamics

• 4 Stages all groups go through to be cohesive and
  successful
• Forming Group members become oriented toward one
  another.
• Storming Conflicts surface in the group as
  members vie for status the group sets its
  goals.
• Norming/Performing Group members move beyond
  disagreement and organizational matters to
  concentrate on the work to be done.

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Universal Group Dynamics

• Forming
• Initial stage Members develop an in or out
  feeling. This highlights the need for the
  facilitator or, in peer-to-peer, the co-
  facilitator to maintain a basic posture of
  concern, acceptance, genuineness and empathy
  toward the group members.
• Nothing takes precedence over this attitude!
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

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Universal Group Dynamics

• Forming cont
• If possible, individually meet with group members
  to orient them to the therapy i.e., relay the
  efficacy of the intervention and determine if
  they are suitable for the intervention (e.g.,
  presence of personality disorders that can
  disrupt the group process).

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Universal Group Dynamics

• Forming cont
• Facilitator, or in the case of peer-to-peer, the
  co-facilitator must recognize and deter any
  situation that might disrupt the formation of
  group cohesion i.e., continued tardiness,
  absences, subgrouping, disruptive extra-group
  socialization and scapegoating.

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Universal Group Dynamics

• Forming cont
• Scapegoating a process whereby anger and
  aggression are displaced onto another, usually
  less powerful group or persons not responsible
  for the aggressors frustration (aka
  displacement or projection)
• Corsini, R. (Ed.). (2002). The dictionary of
  psychology (pp. 863). New York
  Brunner-Routledge.

9
Universal Group Dynamics

• Forming cont
• During this stage there is hesitancy among the
  members and they will be sizing up one another
  and the group. They are wondering if they will be
  liked and respected or ignored and rejected.
• The members will be searching for approval,
  acceptance, respect, or domination.

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Universal Group Dynamics

• Forming cont
• Members will be wondering what membership
  entailshow much they must reveal of themselves,
  what type of commitment they must make.
• Very important they will be looking to the
  leader/facilitator for structure, answers,
  leadership and for approval and acceptance.
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

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Universal Group Dynamics

• Forming cont
• The members search for similarities is very
  common in early groups and group members will be
  fascinated that they are not unique in their
  misery this is part of the foundation for
  cohesiveness (discussed later).
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

12
Universal Group Dynamics

• Storming
• Conflicts surface in the group as members vie for
  status and the group sets its goals.
• This is when the group shifts from preoccupation
  with acceptance, approval, commitment to the
  group, definitions of accepted behavior, the
  search for orientation, structure, and meaning,
  to a preoccupation with dominance, control and
  power.
• The conflict characteristic of this phase is
  among members or between members and the leader.

13
Universal Group Dynamics

• Storming - cont
• Each member attempts to establish his/her
  preferred amount of initiative and power.
• Gradually, a control hierarchy, a social pecking
  order emerges.
• Negative comments and intermember criticism are
  more frequent members often appear to feel
  entitled to a one-way analysis and judgment of
  others.

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Universal Group Dynamics

• Storming - cont
• Advice from the facilitator is given in the
  context of the social code of the group social
  conventions are abandoned and members are told to
  feel free to make personal criticism about a
  complainers behavior or attitudes. Judgments may
  be made of past and present life experiences and
  styles. It is a time of oughts and shoulds in the
  group or a time when the peer-court is in
  session.
• Members will make suggestions or give advice as a
  part of the process of jockeying for position.

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Universal Group Dynamics

• Storming - cont
• At one time or another there most likely will be
  an emergence of hostility toward the facilitator
  this usually arises out of disappointment by
  the group member in their progress Remember
  Progress takes time.
• Another source of resentment toward the
  facilitator is that the member eventually
  realizes he/she will not become the leaders
  favorite child. This does not arise from a
  function of childlike mentality or psychological
  naivete.

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Universal Group Dynamics

• Storming cont
• Encourage members to express their anger or
  annoyance with you or the peer facilitator
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

17
Universal Group Dynamics

• Norming/Performing
• This is the stage where group cohesiveness will
  develop recognition of a common goal,
  development of group spirit, consensual group
  action, cooperation, mutual support, group
  integration, we-consciousness unity, support and
  freedom of communication as well as the
  establishment of intimacy and trust between
  peers.

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Universal Group Dynamics

• Norming/Performing - cont
• In the beginning the group will exhibit much
  pride in their unity and possibly much
  condemnation of the members adversaries outside
  the group. Eventually this glow will pale and the
  group must be allowed to express difficulties,
  conflicts and differentiation otherwise the
  group will fail.

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Universal Group Dynamics

• Norming/Performing - cont
• There are two aspects to this phase
• an early phase of great mutual support (the group
  against the external world) and,
• a more advanced stage of group work or true
  teamwork in which tension emerges as a result of
  the members struggle with his or her own
  resistances.

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Group Therapy Therapeutic Factors

• Eleven Primary Therapeutic Factors
• Instillation of hope
• Universality
• Imparting Information
• Altruism
• Corrective Recapitulation of Primary family group
• Development of Socializing Techniques
• Imitative Behavior
• Interpersonal Learning
• Group Cohesiveness
• Catharsis
• Existential Factors

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Group Therapy Therapeutic Factors

• Instillation of Hope
• Most important at the beginning of the process.
• Instilling hope in someone is therapeutic even
  before therapy starts.
• If you have open enrollment, other members of the
  group can tell how they have been helped.
• Facilitator must be very confident and optimistic
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

22
Group Therapy Therapeutic Factors

• Universality
• You are not alone in this problem.
• Although everyone is unique and has his/her own
  set of problems, within the early stages of group
  therapy group members come to realize that others
  have problems and a welcome to the human race
  experience or were all in the same boat is a
  powerful source of relief to the individual.
• Despite the complexity of human problems,
  certain common denominators are clearly evident,
  and the members of a therapy group soon perceive
  their similarities.

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Group Therapy Therapeutic Factors

• Instillation of Hope
• From you to the support group member they may
  not be informed about what they have, how common
  it is or how treatable the disorder is.
• This is extremely beneficial to the individual.
• From one support group member to another support
  group member it is beneficial to the newcomer or
  ongoing support group member for the members
  reflection on what he/she accomplished, e.g.,
  made the right decision.
• If you understand the problem you can learn to
  control it.

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Group Therapy Therapeutic Factors

• Altruism
• Both recipient and provider can benefit. See
  story below for example there is an old
  Hasidic story of a rabbi who had a conversation
  with the Lord about Heaven and Hell. I will show
  you Hell, said the Lord, and led the rabbi into
  a room containing a group of famished, desperate
  people sitting around a large circular table. In
  the center of the table rested an enormous pot of
  stew, more than enough for everyone. The smell of
  the stew was delicious and made the rabbis mouth
  water. Yet no one ate. Each diner at the table
  held a very long-handled spoon long enough to
  reach the pot and scoop up a spoonful of stew,
  but too long to get the food into ones mouth.
  The rabbi saw that their suffering was indeed
  terrible and bowed his head in compassion. Now I
  will show you heaven, said the Lord, and they
  entered another room identical to the first-same
  large, round table, same enormous pot of stew,
  same long-handled spoons. Yet their was gaiety in
  the air everyone appeared well nourished, plump
  and exuberant. The rabbi could not understand and
  looked to the Lord. It is simple, said the
  Lord, but it requires a certain skill. You see,
  the people in this room have learned to feed each
  other!

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Group Therapy Therapeutic Factors

• The Corrective Recapitulation of the Primary
  Family Group
• Male and female therapists/facilitators become
  mother and father to the group members who in
  turn become the children or siblings.
• Re-evokes situations in a setting where one can
  work on it i.e., make the person/group member
  more conscious (give insight).

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Group Therapy Therapeutic Factors

• Development of Socializing Techniques
• Can be explicit e.g., develop social skills in
  the group developing vocabulary is one tool for
  social skills.
• Can be implicit e.g., learning to become
  comfortable talking about personal relationships
  helps to learn to do this outside of the group
  setting.

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Group Therapy Therapeutic Factors

• Imitative Behavior
• Use of models in the group e.g., explicit how it
  is done implicit how to do it.
• Building a consensus when a group member brings
  up something they need to discuss and is cutoff
  or disrupted by another group member
• Ask the rest of the group (his/her peers) if this
  person (disruptee) is wrong or what they want to
  do,
• Use of the Socratic method what do you (rest of
  the group) think about this situation?
• Be careful not to hide behind the group decision
  if it is the wrong decision (aka consensus
  building).

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Group TherapyTherapeutic Factors

• The development of gratifying interpersonal
  relationships
• The group is a social microcosm (i.e. a
  miniaturized representation of each members
  social universe), a place to learn lessons and
  then generalize them to the outside world (they
  may have problems relating to other people that
  are contributing to their psychopathologies).
• Through feedback from other group members and
  self-observation the members become aware of
  significant aspects of their interpersonal
  behavior their strengths, limitations, their
  interpersonal distortions and the maladaptive
  behavior that elicits unwanted responses from
  other people.

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Group TherapyTherapeutic Factors

• The development of gratifying interpersonal
  relationships
• Interpersonal sequence
• Display of pathology (behavior)
• Feedback from other members self observation
  result in
• Better witnesses of his/her own behavior
• Appreciate the impact of this behavior on
• Feelings of other people
• Opinions others have of them
• Opinions he/she has of himself/herself

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Group TherapyTherapeutic Factors

• Gaining Insight
• Insight occurs when one discovers something
  important about oneself about ones behavior,
  ones motivation, or ones unconscious.
• Results individual realizes they have the power
  to change their behavior.

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Group TherapyTherapeutic Factors

• Group Cohesiveness
• The most common factor (this is the same as the
  therapeutic relationship)
• Cohesiveness broadly defined
• The result of all the forces acting for all the
  members to remain in the group, or more simply
• It refers to the condition of members feeling
  warmth and comfort in the group, feeling they
  belong, valuing the group and feeling, in turn,
  that they are valued and unconditionally accepted
  and supported by other members. In conditions of
  acceptance and understanding, members will be
  more inclined to express and explore themselves
  to become aware of and integrate hitherto
  unaccepted aspects of self, and to relate more
  deeply to others.
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

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Group TherapyTherapeutic Factors

• Catharsis
• A strong emotional reaction often due to sudden
  insight of the nature and causes of deeply hidden
  painful memories.
• An episode of emotional release and discharge of
  tension associated with bringing into the
  conscious recollection previously repressed of
  unpleasant experiences.

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Group TherapyTherapeutic Factors

• Existential Factors
• Recognizing that life is at times unfair and
  unjust.
• Recognizing that ultimately there is no escape
  from some of lifes pain and from death.
• Recognizing that no matter how close we get to
  other people, we must still face life alone.

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Group TherapyTherapeutic Factors

• Existential Factors cont
• Facing the basic issues of our life and death,
  and thus living our lives more honestly and being
  less caught up in trivialities.
• Learning that we must take ultimate
  responsibility for the way we live our lives no
  matter how much guidance and support we receive
  from others.
• Yalom, I. D. (1995). The theory and practice of
  group psychotherapy (4th ed.). New York Basic
  Books.

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Group TherapyBasics

• Ideally, no more than 7 to 8 in each group
• Decide if you want an open group or a closed
  group
• Sometimes you must sacrifice one member for the
  good of the group
• It is the group that is the agent of change (this
  is the norm to strive for)

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Group TherapyBasics

• Your group will have its own culture with norms,
  expectations, behaviors and mores.
• You build the outcome you want.
• Norms of your culture
• active involvement in the group,
• nonjudgmental acceptance of others,
• extensive self disclosure,
• dissatisfaction with present modes of behavior,
• desire for self-understanding, and
• eagerness for change.

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Group TherapyBasics

• Safety you can say what you want without
  ridicule, harassment, or being looked down upon.
• Respect of member to member.
• Attendance.
• Paying Attention.
• Food and drinks maybe not is best (when these
  are present serious conversations rarely take
  place not conducive to therapeutic goals).

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Problem Severity

• Recent statistics show 15 of both sexes aged
  65-years and older suffer with clinically
  relevant depressive symptoms
• 19.6 of both sexes aged 85-years and older
  suffer with same symptoms
• (Federal Interagency Forum on Aging-Related
  Statistics. 2006. Older Americans Update 2006
  Key Indicators of Well-Being. Pp. 27)

39
Behavioral Activation Techniques for Depression

• A parsimonious, multidimensional holistic
  approach to treating depression.
• Easily adaptable to a variety of practical uses.
  Behavioral techniques concentrate on
• Increasing positive reinforcement
• Reducing or undermining punishment from the
  environment
• Activation is the direct target for change

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Definition

• Behavioral activation techniques involve the
  following
• Identification of individualized target
  behaviors, goals and rewards that serve to
  reinforce nondepressive or healthy behavior
• Increase exposure to positive consequences of
  healthy behavior thereby increasing likely
  reoccurrence of such behavior and reducing
  likelihood of future depressed behavior
• Adapted from Lejuez et al. (2001), p. 257

41
A Good Research Model

• Behavioral Activation Group Therapy in Public
  Mental Health Settings A Pilot Investigation.
  Porter, J., Spates, C., Smitham, S. (2004).
• Participants met criteria for DSM-IV diagnosis
  for major depressive disorder.
• Exclusion Criteria
• diagnosis of bipolar or psychotic sub-types of
  depression, panic disorder, current alcohol
  abuse, past or present schizophrenia,
  schizophreniform disorder, organic brain syndrome
  and mental retardation.

42
A Good Research Model

• Treatment modality
• BAGT (Behavioral activation group therapy)
  sessions
• Group format, 95-minute sessions, weekly for 10
  weeks
• 2 Cotherapists
• Group size 6 10 participants
• Mean age 44-yrs old
• BDI-II administered at every therapy session to
  monitor progress on a weekly basis

43
A Good Research Model

• Treatment modality
• BAGT therapy sessions In The Beginning
• Explain and define the therapeutic agent of
  positive reinforcement and its importance.
• Explain the use of the forms utilized within the
  treatment.
• Explain the importance of homework on the
  clients part.
• Explain the importance of not trying to change
  the cognition of the client.
• Explain the importance of the client picking
  out activities that he/she enjoys and not being
  directed by the facilitator.
• To show the emphasis on this modality is on the
  identification of behaviors and activities that
  provide the client with pleasure and interest
  that is currently missing from his/her life.

44
A Good Research Model

• Treatment modality
• BAGT therapy sessions - in the beginning cont
• Obtain a baseline from which to measure progress
  i.e., the Geriatric Depression Scale (is in the
  public domain) when working with individuals aged
  55 years and older (you do not have to use the
  BDI-II with older adults, the GDS is much more
  efficacious).

45
A Good Research Model

• Treatment modality
• BAGT therapy sessions cont
• Cotherapists/cofacilitator (you) should review
  BDI-II scores (GDS or Geriatric Depression Scale
  is better for older adults and one can switch
  between short form and long form to combat
  practice effects, may also use the CUDOS) at
  beginning of each session to monitor progress.
• Forms are in your handouts in the back as well as
  scoring instructions.

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A Good Research Model

• Treatment modality
• BAGT therapy sessions - cont
• Group discussions focused on BA principles
• To explain and define the therapeutic agent of
  positive reinforcement and its importance.
• BA is based on the premise that increased
  activity (i.e., activation) and the resulting
  contact with positive consequences is sufficient
  for the reduction of depressive symptoms and the
  subsequent increase of positive thoughts and
  feelings.
• (Hopko et. al. (2003). A brief behavioral
  activation treatment for depression A randomized
  trial within an inpatient psychiatric hospital.
  Behavior Modification, 27(4), 458-469.)

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A Good Research Model

• Treatment modality
• BAGT therapy sessions - cont
• Soliciting group member disclosure
• Involve members to talk about activities they
  have not done and why e.g., too hard, too
  depressed, etc.
• Planning evaluating interventions
• This is the time to review individuals chosen
  activities e.g., were they too hard?, not
  feasible, etc (try to monitor this at the very
  beginning when they are choosing activities to
  avoid upset. In other words, they should not try
  to reach for the moon make sure activities
  are easy enough to be accomplished.
• Providing feedback to group members.

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The BATD Manual for Group Therapy

• Porter, J., Spates, C. R., Smitham, S. (2004).
  Behavioral activation group therapy in public
  mental health settings A pilot investigation.
  Professional Psychology Research and Practice.
  35(3), 297-301.
• Email jeffreyporter_at_yahoo.com for BAGT manuals
  (both Therapist manual and client workbook).
• It is fundamentally important for you to obtain
  this manual.

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The BATD Manual in its original form

• A Brief Behavioral Activation Treatment for
  Depression Treatment Manual. Lejuez, C., Hopko,
  D., Hopko, S. (2001)
• Excellent, easily implemented structured
  treatment manual useful for individual treatment
  and modifiable to group modality.
• Treatment manual Can be downloaded from
  http//web.utk.edu/dhopko/BATDmanual.pdf
• Again, of extreme importance to obtain this
  manual so that you have a good understanding of
  this therapy model.

50
Treatment Techniques The Forms

• Orientation to therapy
• Instillation of hope explanation of how therapy
  works
• Daily Activity Record
• Establish pattern of activity for previous 7 days
• Functional Assessment
• Establish baseline
• Life Activities Checklist
• Life Areas Assessment
• Behavior Contract
• Activity Hierarchy

51
Treatment Techniques The Forms

• Activity Identification Ranking
• Rewards List
• Weekly Behavioral Checkout
• Master Activity Log
• Activity Graph
• Depressive Symptom Severity Graph

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Types of Assessment

• Therapist/Facilitator-administered assessments
• Interview to determine suitability for group
  membership (see previous criteria i.e., exclusion
  criteria).
• Mental Health Assessment presence of depressive
  symptomology (see functional assessment)

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Types of Assessment Cont.

• Self-report measures to establish baseline and/or
  suitability for group membership (i.e., MMSE
  and/or SLUMS)
• Beck Depression Inventory (BDI-II)
• Clinically Useful Depression Outcome Scale
  (CUDOS available online), or Revised Hamilton
  Rating Scale for Depression (RHRSD)
• Geriatric Depression Scale (GDS)
• Mini Mental Status Exam (MMSE) and/or
• St. Louis University Mental Status Exam (SLUMS
  available online)

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Overview of Session Interventions Functional
Assessment

• Purpose
• Establish daily activity/routine
• To assess which activities in the clients life
  provide a sense of pleasure and/or mastery.
  Client keeps a daily activity log of activities.
• Teach the client the role of self-defeating
  behavior and Aversive Environments in Negative
  Moods.
• To help the client to understand the relationship
  between his/her behavior and moods and between
  the environment and moods. This helps the client
  to understand how he/she can make meaningful
  changes to improve moods.

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Session Interventions Overview cont Mastery and
Pleasure Ratings of Activities

• Purpose
• To assess which activities in the clients life
  provide a sense of pleasure and/or mastery.
  Client keeps a daily activity log of activities
  and rates the degree of pleasure/mastery (0-5)
  experienced after completing the activity.
• Later in the therapy the client selects those
  activities rating high on either side of the
  scale to increase via homework assignments.
• Goal for the client to schedule activities
  during the day so that there is some sense of
  structure and control on the part of the client.
  This also helps the client to identify what
  he/she is doing and to realize that he/she is
  doing nothing.
• Adapted from Behavioral Activation Group
  therapy therapist manual by Porter, J. Spates,
  R. (2004)

56
Session Interventions Overview cont Verbal
Reports of Activities

• Purpose
• To understand what activities the person is
  currently engaging in which reflects current
  functioning. The therapist is able to assess
  whether the client is acting in ways that are
  likely to make the depression worse (i.e., self-
  defeating behaviors). Also gives the therapist an
  idea of the clients interests.
• Ask the client to report on what he/she did at
  specific times during the day.
• Adapted from Behavioral Activation Group
  therapy therapist manual by Porter, J. Spates,
  R. (2004).

57
Session Interventions Overview cont Symptom
Reports from Depressive Measure (GDS)

• Purpose
• To understand what symptoms of depression the
  client is experiencing so that the therapist can
  choose appropriate targets for intervention.
• Look over the measure at the beginning of the
  session and focus primarily on strong behavioral
  and mood symptoms if they are present.
• Adapted from Behavioral Activation Group
  therapy therapist manual by Porter, J. Spates,
  R. (2004).

58
Session Interventions Overview Cont Daily
Activity Schedule Review

• Purpose
• To assess the type and quantity of activities to
  better understand the clients routines and
  regular activities. This helps the therapist to
  better understand why the person is receiving
  little pleasure from life.
• Introduce the Daily Activity Schedule to the
  group members during a group and explain that it
  can be very valuable to keep a record of ones
  activities throughout the day so that suggestions
  for changes in behavior, based on this
  information, can be made.
• Adapted from Behavioral Activation Group
  therapy therapist manual by Porter, J. Spates,
  R. (2004).

59
Session Interventions Overview Cont Assessment
of In-Session Behavior

• Purpose
• To observe first-hand both the depressive
  behaviors, as well as the healthy behaviors, that
  the client engages in during the therapy session.
  These observations can be brought up as they are
  made or at a later time. This is an effective way
  of demonstrating the functional relationships
  between the environment, behavior and its
  consequences.
• Observe the clients behavior in terms of typical
  symptoms of depression as well as in terms of
  generally unhealthy behavior. Observe the
  clients behavior in terms of healthy and
  productive behavior. Examine what is happening
  when problem behaviors or healthy behaviors occur
  and what the results of the behaviors are.
• Adapted from Behavioral Activation Group
  therapy therapist manual by Porter, J. Spates,
  R. (2004).

60
Session Interventions Overview Cont Assigning
Activities to Increase Sense of Mastery or
Pleasure

• Purpose
• To active the client in such a way that he/she
  feels more effective in his/her environment and
  consequently receives more pleasure from
  activities.
• Activities that are likely to improve negative
  aspects of the environment or ones that were
  previously (before the depression) reinforcing.

61
Session Interventions Overview Cont Teach Client
Role of Self-Defeating Behavior Aversive
Environments in Negative Moods

• Purpose
• To help the client to understand the relationship
  between his/her behavior and moods and between
  the environment and moods. This helps the client
  understand how he/she can make meaningful changes
  to improve moods.
• It is important to focus on what the client
  actually does (active behavior) rather than on
  what he/she failed to do.
• You must explain the ABC model to the client
• A is the antecedent to the behavior. This is what
  was occurring just prior to the behavior that set
  up the behavior to occur.
• B is the behavior of interest. This is an
  observable behavior on the part of the client.
• C is the consequences resulting from acting out
  the behavior. Does not imply something bad. All
  behaviors have some consequence, whether good or
  bad.

62
Session Interventions Overview Cont Encouraging
An Active, Rather than a Passive Approach in
Specific Situations

• Purpose
• To focus the client on the function of a behavior
  in terms of being productive or destructive.
• Active behaviors are those that
• Serve to create pleasurable or meaningful
  experiences.
• Serve to ameliorate aversive or unpleasant
  experiences.
• Passive behaviors are those that
• Produce aversive or unpleasant experiences.
• Fail to ameliorate aversive or unpleasant
  experiences.

63
Session Interventions Overview Cont Graded Task
Assignment Progressive Assignment of Tasks of
Increasing Difficulty

• Purpose
• To ensure success and combat the clients
  feelings of being overwhelmed. Make problems
  manageable and the assignment doable.
• Problem definition useful definition of the
  problem in behavioral terms. Be very concrete and
  specific.
• Stepwise assignment of tasks from simpler to more
  complex.
• Immediate and direct observation by the client
  that he/she is successful in reaching a specific
  objective. If the client does not know whether or
  not he/she has completed a goal, then the
  definition of the goal needs to be more concrete
  and specific.

64
Session Interventions Overview Cont Graded Task
Assignment Progressive Assignment of Tasks of
Increasing Difficulty

• Purpose - cont
• Ventilation of doubts, reactions and belittling
  of achievement.
• Celebration of achievements. It is important that
  the client recognizes and be recognized
  (particularly early in therapy) for successful
  completion of goals.

65
Session Interventions Overview Cont Mental
Rehearsal of Assigned Tasks or Activities

• Purpose
• To anticipate pitfalls that might occur while
  completing certain activities.
• Talk through the steps of a planned activity with
  the client, probing when necessary and helping
  the client to problem solve when problems arise.

66
Session Interventions Overview Cont Examining
Alternative Behaviors in Different Situations

• Purpose
• To help the client learn from experiences how to
  better handle problem situations (i.e., how to
  better cope).
• Examine the incident of interest and generate
  alternative options for ways to behave. The goal
  is to identify behaviors to use in the future
  when a similar situation arises.

67
Session Interventions Overview Cont Role-playing
Behavioral Assignments that Involve Other People

• Purpose
• To practice certain behaviors in a controlled and
  safe environment before using them in a real life
  situation.
• Identify a task or skill to practice and
  construct the necessary situation using the
  members of the group as participants.
• Extremely beneficial intervention in the group
  setting.

68
Session Interventions Overview Cont Examining
Potential Outcomes of Different Behaviors

• Purpose
• To help the client process possible outcomes of
  different behaviors before they occur. This
  assists the client in making a decision in a
  situation when it does occur. It also gets the
  client in the mindset of thinking about the
  effects of his/her behavior so that better
  decisions can be made.
• Talk through a particular situation with the
  client and ask questions to help the client
  explore the possible effects of engaging in
  certain behaviors.
• Important to explore best case and worst-case
  outcomes so that the client is prepared for
  either extreme if it occurs.

69
Session Interventions Overview Cont Managing
Situational Contingencies to Maximize the
Likelihood of Homework Success

• Purpose
• To avoid obstacles to successful completion of
  homework in advance of doing the homework so that
  they do not prevent the homework from being
  successfully completed.
• Talk about the homework assignment and possible
  pitfalls. Help the client problem solve by
  creating a homework assignment with a high
  probability of success.

70
Session Interventions Overview Cont Distraction
from Problems or Unpleasant Events

• Purpose
• To shift a clients focus from some problem or
  unpleasant experience to something more
  productive and healthy. Often times depressed
  clients perseverate on a problem and distracting
  them from the problem helps them to loosen their
  stronghold on the thought.
• Assist the client in coming up with alternative
  behaviors to engage in when a problem situation
  arises. Ideally, this distraction behavior should
  be one that is incompatible with the problem
  behavior.

71
Session Interventions Overview Cont Avoiding or
Limiting Exposure to Unpleasant Situations or
People

• Purpose
• To prevent self-defeating behavior that sets up a
  person to be hurt. The goal is to teach the
  client to avoid situations that are likely to
  lead to painful or unpleasant experiences.
• Teach the person specific coping skills for
  getting out of unpleasant situations.

72
Session Interventions Overview Cont Behavioral
Stopping Not Acting in Self-damaging Ways

• Purpose
• To teach the client alternative behaviors to
  those that are self-damaging.
• The therapist helps the client identify behaviors
  that, while still allowing the client to get
  his/her needs met, are healthier (i.e., less
  self-damaging).

73
Session Interventions Overview Cont Direct
Behavioral Instruction by the Therapist

• Purpose
• To teach the client skills that he/she is
  deficient in. This allows a demonstration and
  practice of these skills in a safe setting.
• A particular skill can be identified and
  practiced by the client. Other group members can
  participate and the therapist is present to stop
  action if necessary and make suggestions and give
  feedback in order to shape the behavior into a
  productive behavior.

74
Session Interventions Overview Cont Sensate Focus

• Purpose
• To help the client overcome sexual arousal or
  performance problems.
• This is achieved by shifting the clients focus
  from some sexual act to something less critical.
  This typically involves asking the client to
  focus on non-sexual touching with his/her partner
  and not to have sex. This tends to reduce the
  amount of attention focused on the act, which
  reduces anxiety and often leads to sexual
  activity.

75
Session Interventions Overview Cont Teaching the
Group to Give Themselves Rewards for Behavioral
Achievements

• Purpose
• To increase the amount of pleasure in the
  clients life by having him/her reward themselves
  for accomplishments. This is particularly
  important when the clients environment does not
  provide a lot of pleasure on its own. The
  rationale to provide is that often times
  depressed persons do not acknowledge their
  accomplishments because they are so focused on
  negatives. Rewarding oneself is a way of
  increasing pleasure and acknowledging
  accomplishment.
• Help the client to define tasks in terms that
  will allow him/her to easily determine whether a
  task has been completed or not. Then, help the
  client identify things that he/she can provide
  that are likely to give some pleasure.

76
Session Interventions Overview Cont Dealing with
Specific Behavioral Problems (e.g., sleep)

• Purpose
• To address problems involving overt behaviors.
• Do a functional analysis of the behavior and
  determine what changes can be reasonably made
  that are likely to alleviate the problem behavior.

77
Session Interventions Overview Cont Training to
Overcome Skills Deficits (e.g., assertion,
communication)

• Purpose
• To teach skills that the client is deficient in
  which are contributing to the depression. Often
  time these are basic communication skills.
• The therapist can talk about certain skills and
  what makes them effective and the therapist can
  model these skills for the group.

78
Session 1

• Welcome group members and express optimism about
  their decision to attend
• Briefly state ground rules common to all groups
• Confidentiality no one outside of group should
  be mentioned by name to anyone outside of the
  group (may discuss experiences with
  family/friends but are prohibited from discussing
  other group members experiences or identity).
• No acting out if emotions get out of control,
  the group member should discuss his/her feelings
  or leave the room temporarily if he/she cannot
  control themselves.

79
Session 1

• Ground Rules cont
• No interruptions every member deserves the same
  respect and everyone will have a chance to
  participate.
• Participation everyone is expected to
  participate.
• Homework between sessions activities are
  expected.
• Co-therapist dialogue comment on co-therapist
  dialogue so that when it is utilized the process
  does not confuse members of the group.

80
Session 1

• Ground Rules cont
• Describe some of the benefits of group therapy
• Learn from others who have similar experiences.
• Opportunity to interact with others in a safe
  environment.
• Peer support and feedback.
• Introduction of group members
• Name, personal information.
• What do you want to be different at the end of
  this group experience?
• Introduce the basics (theory) of behavioral
  activation for depression (i.e., how it works and
  its efficacy).

81
Session 1

• Basics Cont
• Depression is characterized by feeling terrible,
  losing interest or pleasure in most activities,
  change in weight and eating habits, change in
  sleep pattern, feeling exhausted all the time,
  feeling worthless or guilty much of the time,
  difficulty concentrating, and thoughts of death
  or dying.
• Depression occurs when changes in a persons life
  occur that reduce the number of pleasurable
  meaningful experiences. This reduction causes
  people to experience some of the symptoms of
  depression (the blues). Once the person becomes
  depressed, his/her way of responding to the
  depression often make the depression worse. For
  example, instead of working to restore the level
  of pleasurable experiences, the person often
  withdraws and further reduces pleasurable
  experiences.

82
Session 1

• Basics Cont
• A final factor is that not all people are equally
  vulnerable to depression. What causes one person
  to become depressed may not cause another person
  to become depressed. Whether or not a person
  becomes depressed is determined by his/her genes,
  his/her history of experiences, and his/her loss
  of physical functioning including chronic
  illnesses/diseases.
• The goal of behavioral activation is to assist
  the client in making changes in behavior that
  will maximize the opportunities for pleasurable
  or meaningful experiences.

83
Session 1

• The goal of behavioral activation cont
• This is accomplished by learning to cope
  differently in a way that increases these
  opportunities. Also, group members are helped to
  change parts of his/her environment so that it
  will become more pleasurable.
• Finally, the group member will learn to nip
  future episodes in the bud by coping better with
  adversity, thereby making him/herself less
  vulnerable to depression.

84
Session 1

• The goal of behavioral activation cont
• It is important to communicate to the group
  members that while behavioral activation has been
  shown to be effective in reducing depression,
  there is no magic change that takes place. Group
  members should expect difficulties in completing
  homework assignments, particularly early in
  therapy. Depression can be relieved through
  continued use of behavioral activation over a
  period of several weeks.
• Role of the therapists
• The therapist is a personal trainer, their job is
  to help clients identify what is going wrong in
  their lives and guide them in actions that will
  help improve their life situations, and thereby
  make them less depressed.

85
Session 1

• Go-Around
• Each member gets 5-10 minutes to tell his/her
  story about why he/she is in the group and what
  his/her life has been like recently.
• Therapists take turns processing information for
  group member and assist them by using open-ended
  probes, clarifications, and empathetic responses.
• After each group member finishes, allow for
  vicarious sharing (not advice) from other group
  members.

86
Session 1

• Co-therapist dialogue to introduce concept of
  homework
• Introduce activity schedules and explain
  rationale for them and ask all group members to
  keep one for the next weeks session.
• Introduce workbooks for group members. Explain
  the purpose of having each group member become
  familiar with the different treatment techniques.
  Ask each group member to read his/her workbook
  and be able to describe how and why the technique
  is used to the group during the next session.
• Spend a few minutes with each group member
  contracting for one additional homework
  assignment that will begin the activation process.

87
Session 1

• Closure
• Thank all members for their participation and
  acknowledge the difficulty of sharing personal
  feelings in a group.
• Be encouraging about the first sessions
  progress.
• Explain that in future sessions, group members
  will be asked for more feedback to peers.

88
Session 1

• Daily
• Activity
• Record
• Homework

89
Session 1

• Begin collaborative assessment of Life
  Activities Checklist - Homework
• to identify enjoyable activities and activities
  of possible future interest

90
Session 2

• Warm up exercise (progressive muscle relaxation,
  imagery, etc). Other therapist reviews clients
  GDS (Geriatric Depression Scale).
• Group members each have a turn presenting the
  treatment techniques from their workbooks. The
  therapists assist by prompting the clients with
  questions or expanding on the clients
  descriptions when needed.

91
Session 2

• Go-Around
• Each group members gets approx. 5 minutes to talk
  about the past weeks experiences and the
  therapists should assist by reflecting, probing
  and clarifying with the mindset of identifying
  behaviors to target for intervening upon with a
  balance between in-session interventions and
  homework assignments
• At this early stage of treatment, the therapists
  will be the primary resources for intervention
  for the group members. Therapists should deflect
  duties to group members when appropriate and when
  there is good reason to believe that the group
  member can handle the task.

92
Session 2

• Closure
• Firm up homework assignments with each group
  member and get a verbal commitment of homework
  from each group member.

93
Session 2

• Create formalized agreements, behavior
  contracts, outlining specific ways
  family/friends can help client to achieve his/her
  goals
• Homework

94
Session 3 - 6

• Warm-up exercise
• Other therapists review GDSs
• Go-around
• Each group member reports on homework
  experiences.
• In-session interventions are utilized more often
  as treatment progresses and more information
  about each group member is obtained.
• Increase homework assignments in terms of
  assignments that may be more difficult and have
  more potential antidepressant value.

95
Session 3 - 6

• Go-around - cont
• As treatment progresses, the therapists should be
  deflecting increasing amounts of responsibility
  to the group members and should be functioning as
  facilitators more than interventionists. This
  involves having clients take on more
  responsibility for their own treatment as well as
  for helping other group members with treatment.
• Closure
• Firm up homework assignments.

96
Sessions 3-6

• Identify potential activities, Life Areas
  Assessment homework

97
Sessions 3-6

• client determines activities he/she would like to
  target
• Family Relationships (e.g., what type of
  brother/sister, father/mother does he/she want to
  be? What qualities are important to the client in
  their relationship with various family members?)
• Social Relationships (e.g., what would an ideal
  friendship be like to the client? What areas
  could be improved in his/her relationships with
  friends?)

98
Sessions 3-6

• Intimate Relationships (e.g., what would
  constitute clients role in an intimate
  relationship? Is he/she currently involved in
  this type of relationship, or would he/she like
  to be?)
• Education/Training (e.g., would client like to
  pursue further education or receive specialized
  training? What would he/she like to learn more
  about?)
• Employment/Career (e.g., what type of work
  does he/she like to do? What kind of worker would
  he/she like to be?)

99
Sessions 3-6

• Hobbies/Recreation (e.g., are there any special
  interests client would like to pursue, or new
  activities he/she would like to experience?)
• Volunteer Work/Charity/Political Activities
  (e.g., what contribution would client like to
  make to the larger community?)
• Physical/Health Issues (e.g., does client wish
  to improve his/her diet, sleep, exercise, etc.?)

100
Sessions 3-6

• Spirituality (e.g., what, if anything, does
  spirituality mean to him/her? Is client satisfied
  with this area of his/her life?)
• Psychological/Emotional Issues (e.g., what are
  clients goals for this treatment? Are there
  other issues besides depression that he/she would
  like to explore?)

101
Sessions 3 6 Cont.

• VIP Activitie