Clinician's Guide to the Get Back to Being You protocol for Behavioural Activation for Depression by The CBT Resource by Marie Chellingsworth

The Clinician’s guide to supporting the ‘Get back to being you with BA’ protocol

Marie Chellingsworth

Photography by Andy Poplar [Vinegar & Brown Paper] ®

© 2020 Marie Chellingsworth. The CBT Resource®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license as a read only document for The CBT Resource Annual CPD & Resources membership holders only. It may be used by the membership holder only for their own individual use in 2020/2021, in the original binding. It cannot be downloaded, photographed, sent electronically, hosted electronically or used by any other party under the conditions of membership. This condition must be imposed at all times and this work cannot be sold for profit, used for training others by the member or any other party, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the individual license holder. The etched glass photography used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper]® and are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression). All other images are used with permission from Unsplash in accordance with their policy. We would like to thank the focus groups and various service practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score of the associated patient protocol material is 11.3 and the Flesch reading ease is 83, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with the patient workbook material and support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol alongside this guide. Disclaimer: This Clinician’s guide is to be read and used clinically alongside the patient workbook ‘Get back to being you with Behavioural Activation (BA)’. It is provided for information purposes only, in conjunction with training in using the protocol from the author. It is not a substitute for CPD training and should only be used by those suitably qualified to support the protocol. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The assessment and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice.

Contents

1-4

Introduction to BA

5-7

The ABC maintenance cycle and introducing BA

Problem statement and goals

9-12

The protocol and session outlines

13-14

Routine regulation (Zeitgeibers)

15-16

Activity regulation: building the hierarchy

17-18

How tasks should be done to prevent boom/bust

19-22

How BA manages negative thoughts and rumination

23-24

Subsequent sessions of BA

25-26

Selection, Optimisation and Compensation (SOC)

27-28

Values exercise

29-30

The importance of homework and structure in LICBT

Manage endings from the beginning

Useful references

About the author and Andy Poplar’s work

Introduction This guide presents an opportunity for practitioners and supervisors to review the clinical skills; competencies and knowledge needed to effectively and efficiently support the ‘Get back to being you’ Low Intensity BA protocol (Chellingsworth, 2020). Behavioural activation is a highly effective treatment for depression, available in both low and high-intensity formats. It has a significant evidence base supporting its efficacy and cost effectiveness. The protocol targets the central maintenance role of negatively reinforced avoidance and re-establishes routine regulation. Rumination and negative thinking are reduced and tackled through structured activity planning based on Socratic dialogue with the patient to help them to make links between activation and thinking. BA aims to help patients re-establish daily routines for the day, increase pleasurable and routine activities and address any important necessary issues (Richards, 2010). BA builds on the work of both Lewishon and Shaffer (1971) and Ferster (1973) and their behavioural models of treating depression. After the rise of Beckian cognitive therapy for depression (1979) which combined activity and introduced cognitive work into a larger component package; Jacobsen et al, (1996), set up a seminal component analysis to see which of the components of the CBT package were necessary for outcome. The three arms looked at activity alone, activity combined with restructuring automatic thoughts and the full step 3 Beck CBT protocol of activity, restructuring negative thoughts and challenging core beliefs and assumptions. There was no significant differences between groups. Activity alone as a component, was found to be just as effective as the other arms, in fewer sessions. There was no clinical advantage to adding in the other components. Results were followed up for two years and maintained. Since then, there have been multiple trials and systematic reviews of the 1

effectiveness of BA as a stand-alone treatment for depression, showing that BA is as effective and non inferior to other forms of CBT in long term follow up, more effective than other forms of treatment and more cost effective to deliver. It also requires less training of the practitioner (e.g. Cuijpers, 2006, Ekers et al, 2007; 2008; Richards et al, 2016). Low intensity BA as a model in the UK was adapted from the high intensity models of BA in the seminal work of Professor David Richards in the collaborative care trial (Richards et al, 2008) and the IAPT demonstration site (Richards & Suckling, 2009). His work resulted in the inclusion of Low Intensity BA within the IAPT Low Intensity CBT national curriculum (Richards, Farrand & Chellingsworth, 2011, last updated 2015) and is used as a the primary treatment in the English and Australian IAPT programmes for depression. There are important differences between high and low intensity treatments for depression, which can lead to drift in Low Intensity BA. The low intensity BA protocol is fundamentally © Marie Chellingsworth (2020). The CBT Resource.

different to the high intensity BA model, the step 3 Beckian CBT protocol and also to the form of activity scheduling found within some guided self-help for depression self help materials. This can cause confusion amongst trainers and clinicians not trained in all models of intensity and by BA experts. Some materials circulated under the title of ‘BA’ by services have also sadly added to this confusion by conflating protocols due to a lack of understanding as BA is a relatively new treatment in the UK. Unfortunately some BA materials also use the term ‘activity scheduling’ used in Beckian models, which can add to this confusion. This requires the practitioner to have a thorough understanding and be able spot when a material is not BA compliant. This could be when it is BA, but is not theoretically correct, when it is a step 3 BA model, and also when it is not BA at all, such as a component of a CBT protocol. At step 2, BA is a stand alone treatment, it is not activity scheduling of previously enjoyed events or historical recording of events and it does not require additional restructuring © Marie Chellingsworth (2020). The CBT Resource.

of cognitions for outcomes. CR added in unnecessarily to BA dilutes the outcome, not enhances it. Guided self-help for depression is a theoretically different model to BA. It is a component package based on the high intensity Beckian CT for depression protocol using activity scheduling and challenging of negative thoughts as a package. It is not evidence based BA. It requires a longer time frame to reach outcome and places more burden on the patient to do the treatment. Both may look similar to a novice eye or those without specific training, as both have activity work initially. While BA may appear on the surface to be a simplistic model, it is theoretically rich in how it works to target and improve across the full range of depression symptoms including cognitions and rumination, resetting the body clock (routine regulation) which can improve sleep, appetite, energy levels and lift mood in a way that is easy to implement and helpful for the patient across levels of severity, complexity and co-morbidity, including depression in long term conditions, dementia and cancer care.

Introduction BA breaks into the cycle of negative reinforcement in depression through targeted activation and regulation of routine markers for the day. When someone is entering into a depressed mood, some of the first symptoms that occur are autonomic physical symptoms such as changes to their appetite, sleep, motivation and concentration. These symptoms disrupt their routine in their day/ night pattern like sleeping, eating and activity - routine regulation makers for the day (called zeitgeibers). These physical symptoms are often residual after the patient subjectively feels better and are a known indicator of increased relapse risk. Therefore a treatment that targets these is important. Thinking and recall in depression becomes negative (a negative filter) with an autobiographical memory bias present. As a result of the symptoms experienced, patients understandably begin to withdraw and avoid situations that bring on more of their difficult symptoms. In the short term this gives some relief from how they are feeling. It helps to temporarily reduce negative thoughts and the physical symptoms and exertion that would be required to do the tasks. Therefore they continue this pattern of avoidance and withdrawal in a negative reinforcement cycle (to avoid their aversive symptoms). As a result, their life becomes more restricted, they lose opportunities for positive reinforcement in their day and there is further dysregulation of their routine patterns. This forms a vicious cycle of avoidance and depression. BA builds back the routine regulators for sleep and appetite into the patients day, reinstating zeitgeibers as rescommended in the BA literature. It gradually increases balanced activities across the week that are routine, necessary or previously pleasurable. It does not increase activity to get reward or pleasure from tasks initially, but to build back the routine regulation pattern of activity itself. It is important to ensure an unhelpful message is not communicated to patients 3

that they do less and feel worse and that through doing more, then will feel pleasure or reward. This is not the case initially. Doing less, avoiding, gives the patient relief from their symptoms. Therefore, they continue this avoidance pattern. This then removes positive reinforcement opportunities and mood decreases further. When they begin to break the cycle, they will likely get an increase in symptoms initially as they begin to activate again as the cycle is reversed. They are unlikely to get significant or stable positive affect from activities during this phase. This is improves as over a short period of time. It is important for patients to be made aware of what to expect in this initial phase of treatment, so that they are not disappointed or think that the treatment is not working. An often misunderstood part of BA in Low Intensity CBT is that important clinical change method time is wasted doing a baseline diary. There is no rationale or need, to do a baseline diary in the majority of cases. This should only be done as an absolute exception only, in a very small minority of cases where the patients activity level is very high already but they cannot see that it is unbalanced. © Marie Chellingsworth (2020). The CBT Resource.

Patients where they are busy but doing routine and necessary tasks only. The aim being to plan a more balanced week and where space and time for homework tasks can be found. However, this should only be necessary or considered if brief discussion with the patient about this in session does not afford this insight alone. That should always be tried first. Rarely, if ever, is a baseline diary actually necessary if a solid rationale for BA, balance and routine regulation of the body clock is correctly given. It does not enhance outcome, but does increase burden on the patient and reduce the dose of the active change methods. Sometimes clinicians think the insight a baseline could provide to the patient is worthwhile. The clinician should be reminded that this is not the case, or in line with the evidence. With the negative bias within depression, it would not render this beneficial and is drift to the diary use within a Beckian CBT model, where the diary is used for gathering data on cognitions and mood and rating hour by hour retrospectively. If there is avoidance, if routines are disrupted or the patients activities are not balanced, BA can be used. To maximise the dose of change © Marie Chellingsworth (2020). The CBT Resource.

methods and to regulate routine markers for the day as quickly as possible, the diary is always planned forwards. This has always been clearly stated (Richards, 2010), but is still often done as a first step of treatment. It is scaffolding not a change method. BA is forward facing and needs to activate as soon as possible, rather than looking retrospectively. The evidence on outcomes and reducing attrition from therapy is very clear that a change method must be utilised from the first session of treatment, not scaffolding tasks alone. It is recommended all clinicians are familiar with the evidence base of BA from the initial component analysis trials, through to the recent cost-effectiveness studies and step 3 models to aid this understanding. The literature on BA clearly advises the important first step of regulation of routine markers for the day as a change method. A second misunderstood aspect of BA is that it does not tackle negative thoughts. This is not the case. BA tackles rumination and negative thinking as a process, switching off the underpinning mechanism and the evidence shows is just as effective as tackling these in addition (See the BA and managing thoughts and rumination section for more details). 4

The ABC maintenance cycle of Depression

Physical symptoms Appetite changes Sleep difficulties Low motivation Low energy Poor concentration

Behaviours Reduction of activities that give a sense of routine and purpose to their day Avoid and reduce activities that previously were enjoyable or necessary

Altered thoughts Lots of negative thoughts about their situation and mood Negative recall Rumination

Introducing BA Practitioner: “You may have noticed that I asked you about three main areas today, how your low mood has affected how you are feeling physically, how it has affected what you are doing or not doing and how it has affected your thinking, as on the diagram here. That is because in a CBT model of depression, these three areas are interlinked and can have a knock on effect on each other. For example, when people are feeling low, they may notice symptoms physically like tiredness, appetite changes and a lack of energy. Thoughts become more negative and people notice more of these thoughts. As a result, understandably they may begin to avoid or reduce activities that make them feel more tired or give them more thoughts. Initially this gives the person some relief from how they are feeling and thinking in the short term. In the longer term however, it leads to more and more impact on how they feel, taking them away from things in life that give a sense of routine in the day and things they previously enjoyed, which leads to more of the symptoms keeping them in a vicious circle that keeps going round and round. Is that something that you feel fits with how you have been feeling?”

A: Physical Symptoms

B: Behaviours

C: Altered Thoughts

Patient: “Yes, exactly I suppose it is yes” Practitioner: “Just to check your understanding and that I have explained it well enough, could you perhaps explain back an example of how your symptoms we discussed are affecting you in the cycle, perhaps starting with your sleep for example?” Patient: “So I have been feeling down and not been sleeping well, waking up early, I feel tired all the time and all my thoughts are so negative. I stay in bed for most of the day at weekends and don’t see my friends and family...and on it goes....” Practitioner: “Yes absolutely, it seems you have a really good understanding. The good news is that just like it took a while to take hold, we can do things that will break into the cycle to help to reverse it the other way, and bring about a more positive changes in each of the areas. I can explain more about treatment method that is recommended and shown to help with this called Behavioural Activation, or BA for short if you would like me to?……..” Patient: “Yes please”

Explaining how the interventions can help to break into the maintenance cycle and reduce low mood and the impact of symptoms they are experiencing is important to engage and motivate the patient into treatment in depression. Using concrete examples of how BA can break into their own particular symptoms they have discussed is important to increase hopefulness that the approach can work for them and decrease any feelings of helplessness. The aim is to increase hope and expectancy of treatment being beneficial for them. To help them to see that change is possible, particularly for any particular symptoms they have mentioned are difficult. For building hope and expectancy of change, it can be useful to share the patient examples in the workbook and vicious cycle diagrams relevant to depression. It is also beneficial to let the patient know that they can begin working on these symptoms from today. This of course needs to be balanced with being realistic about the work involved and commitment to give things a go for a few weeks. Just like the vicious cycle took a while to take hold and initially gave relief from symptoms, as treatment breaks into the cycle, for a while they may notice more symptoms. It is important to normalise this and explain that whilst this may happen initially, improvements start to take place in a short amount of time. Initially doing activities will potentially make them feel more tired and give them more negative thoughts, but that will pass and the treatment is evidence based and helped lots of other people with these symptoms. A good analogy is the Nike® slogan, ‘Just do it’. Initially they are doing the activities for the sake of treatment. Then, as the cycle begins to reverse, their mood will lift and symptoms improve, but they may experience a short term increase in those symptoms as it does. An agreement with the patient to give it a try for 2-4 weeks, then review it together can often be enough to engage less motivated patients. 7

Creating a problem statement and linked goals in depression The problem statement is the baseline of the symptoms that the patient presents with at the start of treatment and always written in the negative, first person. It should be disorder specific and the recognised ABC symptoms of the disorder visible for supervisors in case management supervision. The consequence (impact) of the problem on the patient’s life should be recorded. These symptoms and consequences are then the targets for the intervention chosen. Goals are then set from the problem statement and written in positive terms of where the patient wants to be if these symptoms improve e.g.: Practitioner: OK, so from the problem statement symptoms, we can set treatment goals around these. If you visualise that these symptoms [add relevant patient specific examples here from the statement] have improved, how would daily life be different to now? Where would you be going? What would you be doing? How would you be spending the time that you would have no longer worrying for example? A clear link in the mind of the practitioner and patient to these symptoms and how the planned intervention will target them is essential. The goals the patient is guided to set should be stated in the positive and be things that are realistic and attainable should the symptoms improve. For example, sleeping better, spending more time with their children, seeing friends. This is important to outcomes and structure within LICBT work. Unclear or absent problem statements and misaligned or poorly constructed goals that are not linked to symptom reduction contribute to problems managing time or the structure of sessions effectively and lower outcomes. The problem statement and clear aligned goals can help patients to recognise the session structure and focus and work within it. It can also enable the practitioner to gently remind the patient of the importance of this focus in the agenda at each session and then to maximise the use of the session to work on these problems. Clear linked goals for the problem statement below, would be chosen by the patient and specific, measurable goals linked to the symptoms, such as improved sleep and not waking early, fewer negative thoughts, sorting finances and payments, returning to work and the gym and seeing friends.

“My main problem is feeling down every day. Physically I feel tired and exhausted and low in energy. I don’t sleep well, am waking up early and not being able to get back to sleep. I have lots of negative thoughts such as ‘I can’t be bothered’, ‘I am letting people down’ and ‘There is no point in trying’ I get caught up going over things in my mind. I am not seeing my friends or going to the gym which I used to enjoy. I avoid picking up the phone and dealing with things like bills and paperwork. As a consequence, I am off sick from work, I keep going overdrawn and missing payments, as I am not organised and my relationship with my partner is not great” © Marie Chellingsworth (2020). The CBT Resource.

The ‘Get back to being you’ Protocol for BA The protocol should be delivered by a trained practitioner, supporting the ‘Get back to being you’ self help material, which has been tested to conform to good practice guidelines in self help and have a suitable reading age. In line with NICE guidelines for depression, it is typically delivered over 4-6+ sessions of support (average 4, max 8) with support number dependant upon patient response and engagement to treatment homework (the treatment dose). With each session lasting up to 20-30 minutes for the main protocol change method homework review and subsequent weeks planning (subject to local variation for additional content needed). This should be delivered in weekly sessions, phased out as required as treatment progresses towards discharge. The protocol should end with relapse management. The change methods and scaffolding components of the protocol are:

Change Method/ Technique

Target

Duration/Dose

A change method to target disruption to routine markers for the day (zeitgeibers) that give a sense of routine to the 24 hour period e.g. access to light and dark for sleep and a set time for sleeping/waking; regulating a pattern for eating to target appetite.

Daily times set each week for meal times and sleeping routine for the following 7 days, continued through treatment.

Activity regulation list

A scaffolding task to help the patient to clarify and classify different types of activities they have been avoiding or have reduced as a result of their mood. These should be routine activities, necessary activities and previously pleasurable activities.

A brief one off exercise alongside introducing routine regulation of sleep and appetite and the hierarchy. Activities that increase daytime access to light and evening darkness and good sleep habits should be easier early tasks, along with increasing activity.

Hierarchy of activities

A scaffolding task to help patients to break down the tasks from their list into easier and more difficult activities to begin to build back each week, in a graded way that feels manageable.

A brief exercise carried out as part of a session with the patient and finished as homework if incomplete (alongside starting the first easier BA tasks and routine regulation to ensure an adequate dose of the change methods is delivered). Any difficult tasks broken down into easier steps during the course of treatment planning in subsequent sessions, should be added to the hierarchy throughout treatment.

Activity Regulation

Targets negative reinforcement cycle of avoided and reduced activities, increases a more balanced routine, reduced negative thoughts and rumination and provides positive reinforcement opportunities.

Weekly activity regulation, with a mix of routine activities, previously pleasurable activities and any necessary tasks that have to be completed that week from the hierarchy, tackled from easier to most difficult tasks as treatment progresses. The patient should balance the tasks throughout the week. An activity task is not required every day and days with no planned activity enable learning to be drawn from activating.

Routine Regulation

Should be task reinforced as a weekly homework item and reviewed with the patient through treatment.

*Values Exercise

A scaffolding task for those patients who are unable to do a valued activity anymore or who really struggle to think of previously enjoyed activities. One activity e.g. walking, can be used to work out what they valued in the activity e.g. time by myself, time outdoors, exercise and further activities that may them into contact with these values from the other activity.

*The clinician should remember that adding more complexity to BA has not been found to increase outcome. This should be used as scaffolding only when necessary to activity regulation. For example, for patients where there is an actual loss of function such as a physical health injury e.g. post stroke, surgery, an accident or injury with a prolonged recovery period.

*Selection, Optimisation and Compensation (SOC)

A scaffolding task for patients who have a limitation as a result of physical injury or decline in functioning as a result ageing, who would like to get back to an activity or could get back to it, but where the activity needs to be selected down, optimised to enhance their experience and any compensatory strategies put into place.

*The clinician should remember that adding more complexity to BA has not been found to increase outcome. This should be used as scaffolding only when necessary to activity regulation. For example, patients where there is an actual loss of function such as a physical health injury or loss of function e.g. post stroke.

Managing negative automatic thoughts and rumination

A change method within activity regulation to target rumination and negative thinking as a process in subsequent weeks. This is done within BA for all patients to target negative thinking after the first session of BA homework is completed.

After the first session of activities are completed, the learning should be drawn from the patient that when they are engaged in a task they ruminate less and have fewer negative thoughts, compared with when they are not engaged in a task or activating e.g. when lying in bed awake. In subsequent homework planning of activities, tasks should be placed at times of higher rumination and negative thinking to break the cycle and decrease the frequency of negative thinking.

Relapse management

A short exercise to target early warning signs of relapse, normalise mood fluctuations and help the patient to consolidate learning of the change methods to assist if they need them in the future.

Used at the end of treatment, the patients learning of early warning signs of routine disruption, autonomic, cognitive and behavioural changes as well as reinforcing the change methods and learning from treatment.

The ‘Get back to being you’ Protocol for BA Typical Treatment Outline Note: This is not a rigid, prescriptive list but an indicative treatment structure to enable the correct dose of the change methods as homework during a course of brief BA for depression within a Low Intensity CBT format. Routine regulation should be front-loaded to assist with the autonomic symptoms of depression and begin to build back a solid foundation of routine to the patients day. Supporting scaffolding exercises like thought suppression, values to identify activities and Selection, Optimisation and Compensation (SOC) should only be used if required based on individual clinical need, not with every patient. Session 1: 1. Agenda Setting 2. Socialisation to the BA maintenance model of depression and treatment rationale given for BA 3. Routine regulation for sleep/wake times and meal times introduced and times for week 1 planned 4. BA list and hierarchy started 5. Homework tasks agreed and plan written down 6. Ending Session 1 Homework: 1. Daily routine regulation for sleep/wake times and meals to optimise the dose of the routine regulation change method 2. Completion of activities hierarchy/list if not completed in session 3. Carrying out 1-2 (max 3) balanced activities from easier section to optimise the dose of the activity regulation change method Session 2: 1. Agenda Setting 2. Review routine regulation and activity regulation homework practice, reinforce daily practice of routine regulation throughout treatment, any learning through using the intervention for the first week should be socratically discussed and consolidated, or any difficulties in implementation reviewed in terms of internal or external barriers and managed accordingly. 3. Review activities completed in the first week, manage any difficulties in implementation or any misunderstandings such as how much of the task to complete to avoid boom/bust, reflectively compare times with activities planned in and completed with times without and knock in impact on subsequent hours/days. Pull out the learning and implications as a result. Compare and contrast times of activity, versus times of no activity on negative thinking and rumination and the implications of this for where to put future homework tasks. Review access to outdoor light in day and dark in the evenings and reinforce the tasks to aid this. Discuss importance of these for routine, sleep and breaking the cycle. 4. Planning for week 2 homework based on week 1 progress, ideally putting some tasks in at time of rumination to help the patient to see the link between negative thoughts and activity/ tasks if this hasn’t already been noticed by the patient. 11

5. Homework tasks agreed and plan written down 6. Ending Session 2 Homework: 1. Daily routine regulation for sleep/wake times and meals, with times adjusted for the week based on week 1 and commitments over the next 7 days, if necessary. 2. Carrying out 2-3 further balanced activities from the hierarchy spread and balanced across week 3. If a necessary task is needed that week, break it down and plan it as part of the balanced tasks Session 3/4: 1. Agenda Setting 2. Review routine regulation and activity regulation homework practice, reinforce daily practice of routine regulation throughout treatment, any learning through using the intervention for the second week should be socratically discussed and consolidated, or manage any difficulties in implementation, looking at internal or external barriers. 3. Review activities completed in the first week, manage any difficulties in implementation or any misunderstandings such as how much of the task to complete to avoid boom/bust, reflectively compare times with activities planned in and completed with times without and knock in impact on subsequent hours/days. Pull out the learning and implications as a result. Compare and contrast times of activity versus no activity on negative thinking and rumination and other depressive symptoms and implications of this for next weeks plan. Review access to outdoor light, dark in evenings and exercise if tasks completed for this. Discuss importance of these for routine, sleep and breaking cycle. 4. Planning for week 3 homework based on week 2 progress, ideally putting some tasks in at time of rumination to help the patient to see the link between negative thoughts and activity/ tasks if this hasn’t already been noticed by the patient in week 2 and continuing this if it has, continue tasks that will assist with access to daytime light and evening darkness to aid sleep. Homework tasks agreed and plan written down 6. Ending Session 3/4 Homework: 1. Daily routine regulation for sleep/wake times and meals continued, with times adjusted for the week based on week 3 and commitments over the next 7 days, if necessary. 2. Carrying out 2-3/4 further balanced activities from the hierarchy spread and balanced across week 3. If a necessary task is needed that week, break it down and plan it as part of the balanced tasks Treatment is continued as above until relapse management can be initiated (usually 4-6 sessions of treatment).

Routine Regulation

The first change method within BA is routine regulation. Routine regulators are markers for the day that help to regulate the body clock and mood, known as ‘zeitgeibers’. Zeitgeiber is a German word that means ‘time-givers’; routines that help the internal body clock to keep in synch with the world around us and the body’s circadian rhythms operating in an orderly way. These can be any external or environmental cues that synchronise our biological rhythm.

social routines and habits in the persons day (for example avoidance behaviours such as not drawing the curtains and sitting in the dark, snacking instead of regular meal times, not completing usual social activities, going to work and the changes to sleeping times and bedtime routine). These depressive behaviours then serve to further maintain the routine marker disruption and worsen mood even more, keeping the person in a vicious cycle of depression.

One example is light, which controls melatonin production, the hormone responsible for sleep, which in turn sets our circadian rhythm. Similarly environmental cues like routine meal times affect appetite regulation and our usual activities undertaken affect activity regulation. We have a dependence on these routines to maintain our mood. Our biological clocks for example, operate according to our circadian rhythm. Triggered by physical zeitgeibers, the light and dark, our dependence on social habits at certain times during the day such as eating, social contact, work and routine. Our bodies become dependent on these routine markers. Since our internal body clock is set by these zeitgeibers, disruption to these routine regulators causes a knock on effect for the person. Good examples of this disruption outside of depression are jet lag or shift working.

Regulation of routine is done as a primary change mechanism within BA to begin to regulate the body clock back into synch. This breaks into cycle of the autonomic physical symptoms of depression such as appetite, sleep and energy and improves the patient’s ability to use activity regulation due to the knock on effect of these symptoms improving.

When someone is depressed, some of the first symptoms experienced are the autonomic physical changes, such as sleep disruption, appetite disruption, motivation and then the behavioural changes in activity that occur as a result of the depression that disrupt usual 13

Routine regulation of daily time givers and cues to synchronise the internal body clock to the world around us, such as our sleep and appetite; are often misunderstood by those without a clear understanding of the BA literature or in-depth training. These can often be confused with routine activities in activity regulation, for example hoovering, or washing up for example. It is therefore important the practitioner understands the rationale for routine regulation, and how this aims to give a daily routine pattern to the patient’s day. Alongside the practitioner being able to understand routine activities which are a part of activity regulation to target avoidance, alongside necessary and pleasurable activity categories. These activities are balanced and spaced out across a week. © Marie Chellingsworth (2020). The CBT Resource.

An example of how to introduce routine regulation to the patient is as follows: Practitioner: “We all have things in our day that give our internal body clock cues and a sense of time. They help to regulate things for us like our sleep, appetite and our mood. When someone is depressed, these usual markers for our day, like our sleep times, the times we eat, as well as what we do during the day, can become disrupted by the symptoms. When this happens, it then further affects our mood, our body clock becomes even more disrupted, further affecting our mood, energy, levels, sleep and activities in a vicious cycle. We can begin to tackle that cycle straight away, by regulating a routine pattern back into your day. This is a helpful way to begin as it does not place too much additional burden on your day when you are feeling depressed. ” Patient: “That makes sense. I will try anything to feel better” Practitioner: “If you think about a usual 24 hour period, usually our daytime is set by light and the night to the dark. It is the light we get in the daytime that helps our body produce melatonin, the sleep hormone. In the evening as it gets dark, the melatonin is released by the body and triggers us to sleep. The pattern of times we usually go to bed and get up are signals to our body clock to sleep and to then wake. You have mentioned your sleep is affected currently. So we can set a realistic time to go to bed by each day and a set time to get out of bed by in the mornings to help with this. We don’t have to make it too early, as I know you said you currently stay in bed © Marie Chellingsworth (2020). The CBT Resource.

most days, but we can set a time that feels OK for you to get out of bed by, and to go to sleep at each for the next week?” Patient: “Yes” Practitioner: “The other important thing to help to do this, is access to light. Sometimes when people are feeling low, they stay inside all day, sometimes with the curtains closed. SO their body doesn’t get the access to light it needs” Patient: “Yeah I am guilty of that....I just sit there if I do get out of bed at all” Practitioner: “What we want to do is when you get out of bed, try to be in natural daylight as much as you can during the day, even if you’re inside the house. Pulling the curtains each day is a routine activity we can build into the activity regulation section. Then in the evening shutting the curtains again and trying to keep light levels dim until your bedtime, to cue your body to prepare for sleep”. Patient: “Yes, I can do that” Practitioner: “We can set those times now on your diary and also set one for routine meal times for the next 7 days. For now, it doesn’t matter so much what you are eating, it is about helping your body to have those routine time cues for your day. We can plan them on your diary where we will plan activities each week. Some people find setting an alarm or reminder for those times on their smart phone or device helpful” 14

Activity regulation: building the hierarchy

When creating the list of avoided activities, both previously pleasurable, routine and any necessary tasks should be listed. It is important to explain the definition of each type to the patient. Routine activities should not be confused with routine regulation. Routine activities are things that have to be done regularly, such as cleaning, washing up, showering, pulling the curtains etc. Pleasurable things are things the person used to previously enjoy or participate in like hobbies, interests, social and leisure activities with friends or family, spending time with any children, or their partner. Often exercise, or things like walking the dog for example, can fall into the routine category for some patients and for others, pleasure. Necessary tasks are often a point of practitioner and patient confusion, that needs clarity. For the context of the BA intervention, necessary tasks are tasks that must be completed by a deadline or there will be an immediate health of financial consequence from not doing so at that point that week/ day. For example, taking a medication that can cause an immediate health consequence if not taken, such as insulin if diabetic. Paying normal first letter or invoice bills is routine activity and would go in the routine section of the list. They are not a necessary activity 15

unless they are overdue on a final reminder or there is an immediate consequence if not paid at that time. For example, a necessary task would be a bill where there is an immediate consequence to not paying by a certain date e.g. a parking fine, or being cut off by an energy supplier due to final notification and warning by letter. When depressed, patients can view every task as necessary and it feel overwhelming. The necessary tasks should move to the hierarchy and be broken down into easier stages to be completed in the diary by the deadline. If a task does not require breaking it down, it would be added to the diary in the week before/of when it needs to be done by. When the definition of necessary is used correctly for BA, it is usual that patients may not have a necessary task to complete each week during treatment. It helps to break the cycle that the patient feel that these tasks are overwhelming. It can be hard for some patients to recall previously enjoyed activities due to the negative autobiographical memory bias, concentration and motivation difficulties. Therefore patience is recommended. Positive encouragement to help the patient recall specific events they did and to make gentle suggestions e.g. “what did you used to do with your children when they were off in © Marie Chellingsworth (2020). The CBT Resource.

the holidays?” “What about at weekends or after school?” “You mentioned your friend James, where did you usually go when you got together?” can aid this task. It can also be easy for patients negative affect and recall to result in challenges in completing the list, such as negative predictions e.g. “but I wouldn’t enjoy it now” or “yes, but I have tried”. Remember, the patients mood and negative can interfere here and working around this gently and with good common factor skills is important. Remind the patient that the aim is not to get pleasure, enjoyment or a sense of reward from doing the activity at first. It is activity regulation to break the cycle and help the body to get back into synch. Over time, enjoyment will come back, as mood lifts. Although they may have also tried doing things again before, BA is structured and graded in a particular way to make it manageable and activities are balanced across the week. When patients have given a harder

task for the list e.g. cleaning the bedroom, an easy way to help generate more for the list is to break down “what would be easier than that?”, “What about the en-suite, would that be easier or more difficult than cleaning the bedroom?” Due to deficits in problem solving skills when someone is depressed and the black and white thinking that occurs, it can be hard for patients to see the shades of grey in terms of easier tasks without gentle support from the practitioner to help them to consider alternatives. If, on an individual patient basis, there is a limiting physical health condition, injury or loss that is impacting on creating the hierarchy, the values exercise sheet or SOC can be used to generate more pleasurable activities for the list from the one activity. This is further explained in more detail later in this guide.

It is unrealistic that the hierarchy will be fully completed within a first session, along with also ensuring change method homework of routine regulation and easier activities is planned sufficiently. Completion of the hierarchy should never be prioritised over enabling the patient to start the active dose of BA change methods from the first sessions homework. Therefore, in session one, aim to complete 1-2 avoided activities in each section and to ensure that there are some easier tasks to start the treatment and plan the first weeks BA tasks from these. This ensures enough time is left to ensure the patient is clear on how much of the activity to do, when to stop, to act to the plan, not their symptoms and to be sure on their routine regulation times for the week The hierarchy gaps between these items put in can then be finished for homework or next session.

How a task should be done to prevent boom/bust

A common but very avoidable problem encountered in BA is that the patient does too much of one or more activities in a week. They become exhausted and overwhelmed by symptoms. As a result, they do not activate as planned afterwards acting. This is preventable by ensuring the patient understands the condition of stopping when their energy tank is still half full, at the point when they could do the same amount of the task again. The patient needs to understand why this is an important condition, to not overwhelm them with negative thoughts and physical symptoms of depression increasing at an unmanageable level while the cycle begins to break. How to explain the purpose of the activities in BA: “With BA, the activities are being done purely for the sake of homework to break the cycle and not to complete them as you would have done before this. Avoidance of these activities gave some initial relief from the symptoms of depression. Reversing the cycle will mean that the symptoms, like negative thoughts, or tiredness for example, may initially become more noticeable for a short period of time. For a while, tasks may 17

be harder to do than they were before, as the cycle reverses and it is important that this does not lead to an overwhelming amount of the symptoms. It will also take a while for enjoyment of any previously pleasurable tasks to come back or a sense of reward from doing the tasks. For a while, remember you are just doing them to get back into having activity as part of building back in a routine. Enjoyment will come back, once the cycle reverses, for now, think ‘Just do it’” Helping the patient with guidance of how much of the task to complete is also important and often left undone when homework planning, resulting in boom/bust that could have been prevented. An activity in BA must never be graded on time or amount e.g. not to plan to hoover for 10 minutes or swim for 50 lengths, or graded on how much they would previously have been able to complete prior to depression. This could be too much based on their current physical symptoms of depression and lead to fatigue, too many negative thoughts and a boom/bust occurring. When setting homework tasks, a clear discussion should take place on how much of each task to do. An easy way is to give the patient a © Marie Chellingsworth (2020). The CBT Resource.

condition of BA that they should complete any planned task until their energy tank is still half full, when they could do the same amount they have just done again. This is something patients can easily remember and has a visual prompt within their patient material with the fuel gauge on the cover. How to explain how much of a task they should do: “In BA, it isn’t how much of a task that you do that is important, it is just doing it. That is because you are doing the task for the sake of treatment and we don’t want you to do too much, leading to getting too many unpleasant symptoms back as the vicious cycle reverses. So if a task was to wash up for example, the aim is not to do all the washing up that is there, or to stop after a certain amount of time. The task is just to do it, to do an amount that feels manageable and isn’t too much, as that can affect your energy levels for the whole week. A good way to think of this is working to the condition of BA, to stop when you have half an energy tank left. Like a fuel gauge, you do the planned activity and stop at the point that you could still do the same amount again. You stop when your energy fuel tank is still half full and you could do more © Marie Chellingsworth (2020). The CBT Resource.

of the task, leaving a reserve in your energy tank for the rest of the week. As your mood lifts, so will the amount you can do within that condition without giving an overwhelming level of symptoms back as the cycle reverses. For example you may have been able to swim for an hour before, or do 40 lengths, in BA the aim is not to complete a certain amount of lengths or spend a certain amount of time swimming, instead, the aim of a completed task in BA would be that you get to the pool and swim, carrying out the planned activity, despite how you were thinking or feeling at that time. You would swim until you felt you had half a tank of energy left and could still swim the same amount again, then stop at that point. We don’t know how much that is until you do the activity.....Can I just check your understanding of what we have just discussed and how much of the first activity you have on your diary you need to complete?”

How BA manages negative thinking and rumination as a process

When depressed, thoughts become more noticeably negative and selective attention is paid to these thoughts as they are mood congruent. Rumination is a behaviour that is best treated as a process, just like worry in GAD. A negative bias in processing information occurs. Negative thoughts and ruminations usually focus on the self, depression symptoms and their causes and consequences, negative predictions about the future and others and negative recall of past events, as a result of the autobiographical memory bias present in depression. The patient experiences an increase in negative automatic thoughts that are situational specific which has a knock on effect in the vicious cycle. It is often a misconception of the theoretical underpinning of BA in novice therapists and practitioners that it does not target negative thoughts or cognitions. It does so as a process, targeting the underpinning mechanism of rumination and negative thinking as a symptom of depression, tackling negative thoughts as a process of depression that can be decreased via targeted activation. 19

It deals with thoughts as a process rather than individual content of negative thinking. Some clinicians mistakenly add in cognitive restructuring to BA without understanding that this is not required, is drift from the fidelity of the process of BA and dilutes the dose of the effective change methods within the protocol with no added benefit. It should be remembered that BA has been shown in RCT and meta-analytical studies to reduce depression, rumination and negative thinking just as effectively without needing cognitive restructuring techniques and reduces negative thinking and rumination (e.g. Jacobsen, 1999; Ekers et al, 1998, 2008, 2014). A recent study (Fernandez et al, 2017) examined cognitive therapy versus behavioural activation in the management of negative automatic thoughts in anxiety provoking situations in depression and found BA to be the only one to significantly reduce negative automatic thoughts. The term rumination for the process of going over these thoughts is due to the similarities with ruminant animals regurgitating cud (chewing the cud over and over). Cows are one example of ruminate animals, going over © Marie Chellingsworth (2020). The CBT Resource.

and over the same mouthful before digestion in this way. Rumination is not simply thinking negative thoughts over and over again, but is paying repetitive, selective and passive attention to the symptoms of distress in depression and the causes and consequences of the depressed mood. Some theories state that rumination is a function towards unmet goals and to understand unresolved situations. Ruminating on past events and also depression symptoms, causes and consequences may therefore be a strategy aimed at resolving the unmet goal of improving mood, but one that is not effective to make progress towards that goal. Rumination has been shown to have a maintenance effect upon depression and increase symptoms. Simply trying to shift attention onto more positive or balanced thinking has been shown to not be an effective strategy to break into ruminative negative thinking. Hamilton et al (2015) showed in a meta-analysis that rumination is likely when the default mode network of the brain (DMN) are active when the mind wanders, daydreams or is lost in self-referential thought with depression disrupting the brains natural process in a maladaptive way that keeps the patient locked into a vicious cycle or © Marie Chellingsworth (2020). The CBT Resource.

rumination and negative thinking. When patients activities are decreased and their symptoms of depression disrupt their routine and usual engagement of tasks, rumination increases, further maintaining the cycle. Typically patients notice more rumination on negative thoughts when trying to relax, drop off to sleep, or when not engaged in an activity. There can also be a conditioned response to certain behaviours such as sitting in a certain place or bed for example that can trigger rumination. Engaging the brain in a task away from these times where rumination is higher can break this cycle of negative thinking and rumination. Within Low Intensity BA, targeted activities are placed to disrupt rumination and the patients attention is drawn to the fact they ruminate less when engaged in a task, versus when engaged when reviewing homework from the first session of BA activity regulation. A typical way to draw out the learning from homework socratically around negative thinking and the link with activity in BA is as follows: 20

How BA manages negative thinking and rumination as a process Practitioner: “So you managed to complete the tasks you planned in, which is excellent, thanks for talking me through those. I know how difficult that can be when your mood is low to get going with building things back in, so I am really pleased to hear that” Patient: ‘‘Yes. I still don’t feel any better, but I know you said it takes a bit of time” Practitioner: “Yes absolutely, in the short term you may notice more symptoms as we break into the vicious cycle and just like it took some time to take hold, it can take a short while to notice the improvements too, but you have taken the first steps to breaking that cycle. That’s excellent and we are on the right track to feeling better. We talked before that you noticed lots of negative thoughts and can ruminate over things in your mind. Can I ask, when you were doing the first activity, how were your negative thoughts during the activity? “ Patient: “Erm....well not too bad actually. I didn’t notice them to be honest. I was too focused on the task’. Practitioner: “OK you didn’t notice any whilst you were focused doing the planned activity. How about on Wednesday when you didn’t have any activities scheduled in, what did you do Wednesday? Patient: “I didn’t do anything. I stayed in bed until the time I had to get out of bed by that we set. I didn’t feel like getting up at all. I had woken up quite a bit before that but didn’t want to get out of bed until I had to. I felt so tired and low. I just sat downstairs and watched TV for the rest of the day. Well, I put Netflix on, but I couldn’t really take it in to be honest, it was just background noise”. Practitioner: “OK, so you stayed in bed awake 21

after waking up, then you sat downstairs with Netflix on but didn’t really watch it. When you lying in bed awake, but not asleep, how were your negative thoughts at that point?” Patient: “Not great, I found myself thinking a lot about my mood. What will happen if I don’t get well and what people must think of me at work....” Practitioner: “That doesn’t sound particularly nice, to lay there and be thinking about those concerns. How about when you were downstairs with Netflix on, how were your negative thoughts at that point?” Patient: “Yes, Wednesday was a bad day overall really. I just felt really down and lots of those kind of thoughts all day” Practitioner: “OK, that’s interesting, so you noticed that when you had the task on Thursday, you didn’t notice those type of thoughts while you were doing the task, but when you weren’t engaged in an activity, you had a lot more of those thoughts, ruminating on them at those times, is that right?” Patient: “Yes....” Practitioner: “One thing we know about rumination thoughts is that they do tend to happen when someone is not engaged in an activity or task, when their mind is able to wander off, like when you are lying in bed trying to get to sleep, or after waking up. These thoughts distract you from what is going on around you and focus you on how you feel internally. Like when you were watching the TV, you say you couldn’t really take it in. When someone is really engaged in activity or task, they notice fewer thoughts. So what you have noticed there is really important and a © Marie Chellingsworth (2020). The CBT Resource.

good outcome we would expect. What do you think that tells us about where it is best we plan in tasks for next week?

the impact of targeting times of rumination with activity, it is helpful to say to the patient that they can do this.

Patient: “That where we plan the tasks, I should have less thoughts?’

As a clinician, it is also important to remember that doing an activity in this case, just as when refocusing away from a worry in GAD, is not a distraction, the rumination or worry is the distraction, it has already taken their attention away from what they would or could be otherwise doing externally, into their internal world of thoughts and symptoms. The activity breaks the cycle of rumination by doing a task that takes their attention back where it should be in the present moment.

Practitioner: ‘Yes, so we can try and see if that happens for you, we can plan some tasks in at times when you notice you usually ruminate more to try and break that link....Shall we try that this week?..............” The aim is that by helping patients to make the link between activity and ruminating, that outside of planned activity times, patients may notice they are ruminating and make a link with doing an activity or task. When reviewing

A useful analogy that is easy for patients to keep in mind about rumination is the old Irish proverb: Remember you will never plough a field by turning it over and over in your mind’ (Anon).

Subsequent sessions of BA

Routine regulation review: With routine regulators we are attempting to keep a structure to the waking day to help the body clock to reset. This needs a daily structure each day of these routine markers. Your review should both ask questions to bring to the patients attention to any learning they may have noticed, or things they may consider from having completed the routine regulation for a week. The patient may notice helpful aspects of the routine markers they have put into place quite quickly in the first weeks of treatment, but these may need reflection and discussion to help bring these into the patients awareness. The routine should begin to give a sense structure to the day. Having a sleep and wake time should help to begin to regulate sleep and to work on the physical impact of sleep disruption on the body and energy levels over time.

day being regulated (meals and cooking can be tackled via the activity regulation hierarchy if they want to work on this). Reinforcement of the benefits of routine regulation should be discussed and task reinforcement used to engage the patient in continuing the routine throughout treatment, including planning for the next 7 days homework within the session each week. The idea is to keep a pattern of these times in place as much as possible. Therefore it is best not to change or alter the times for meals for the subsequent week if possible, other than if the patients’ work or other commitments mean these would need to change e.g. in the case of travel or work changes. If the patient has noticed, or your Socratic questions helps them to realise that spending time awake in bed leads to an increase in negative thoughts or a lower mood at that time through your review, you can discuss and agree to bring their get out of bed The structure of regular meal times should time closer to their wake up time for the next help to give both a time stamp signal to week. Similarly, if they set a go to bed time of the body clock, but also begin to help with 11pm but are not sleeping until midnight, the regulation of appetite. Our body sends signals time to bed can be gently shifted to increase to expect food based on our routine pattern. the time spent in bed for sleeping only. Due to appetite changes in depression and As sleep improves in subsequent sessions, routine disruption to meal times, this can additional time can be added if they require a be impacted even further as a result of the longer sleep period, but try to keep the wake patient not having these usual cues to eat from up time the same. Access to light during the the body. Remember for now it isn’t about day and keeping things darker in the evenings what they are eating, but about the times of and a routine before bed to cue the body for 23

sleep and enable melatonin production should be discussed with the patient to remind them of the importance of this aspect. Activity regulation review: When reviewing the activities the patient had planned to carry out, the aim is to collaboratively reflect upon how each activity went; how they felt prior to doing the activity and also again afterwards, to normalise any increase in symptoms as a result in the initial phase of treatment and to compare and contrast symptoms at times of activity compared with times of no activities being planned in. Helping the patient to explore and notice any changes in their affect and cognitive, behavioural and physical symptoms at specific times related to activity regulation and the implications of this for next weeks plan should be discussed. The benefits of activity regulation to restoring mood and resetting the body clock should be reinforced. If the patient expresses disappointment that mood has yet to improve, this should be problem solved and the patient reminded the cycle will take a while to reverse and that symptoms may initially go up or stay the same for a short while as this happens, then improve. Any misunderstanding that activity needed to be done each day in initial weeks can be clarified and the outside-in nature of carrying out the plan despite internal thoughts or feelings reiterated. © Marie Chellingsworth (2020). The CBT Resource.

In subsequent sessions of BA, a routine normal pattern to activities should begin to be built back e.g. a pleasurable activity after a routine or necessary task, a routine or necessary task after a pleasurable one for example. Positive reinforcement should take place for any homework completed. If they have not completed the routine regulation every day or the planned activity regulation across the week, positive reinforcement for attending the session should be given. It is important to reinforce how great it is they have still attended the review session and the support you can offer to problem solve the barriers and make a new plan. It can be helpful to ask the patient if you could do anything differently or explain things better and gain feedback. The internal or external barriers that got in the way then problem solved for next time and any misunderstandings about BA resolved. The importance of a daily pattern being needed for routine regulation and carrying out the plan despite any negative thoughts or internal feelings of depression, to break the cycle of depression can be reinforced and comparisons drawn about days where the routine regulation or planned activities were completed versus not completed also reflected upon to move forwards. 24

Selection, Optimisation and Compensation (SOC) Selection, Optimisation and Compensation (SOC) is an optional scaffolding technique to augment planning of activities in circumstances where patients have physical limitations or losses as a result of injury, illness or losses in functioning as a result of ageing, it can be hard for them to contemplate becoming behaviourally active again, as the things they used to previously enjoy or that gave them a sense of routine feel impossible to do in the same way. Selection, Optimisation and Compensation (SOC), a theory originating from gerontology (Baltes & Smith, 2002; Baltes, 1990; Baltes, 1987) is a way of helping people deal with challenges associated with ageing, injury or physical health limitations and still be able to help them to carry out an activity and optimise their experience. This approach has been successfully used within high intensity CBT approaches for some time (Laidlaw et al, 2003; Laidlaw, 2105) and has been augmented within the recent Low Intensity CBT with Older People national curriculum and training (Chellingsworth & Laidlaw, 2013; 2015) and within Behavioural Activation self-help materials for patients (Chellingsworth, 2019; Chellingsworth, 2017, Chellingsworth, 2016, Chellingsworth & Farrand, 2015). It would only be used if needed with specific patients. The stages of using SOC to enable a patient to continue an activity despite an injury, physical health impact or decline in functioning due to ageing are:

Select

Selecting down the activity to be able to do it and still optimise, not decrease their experience of it

Optimise

Optimising the patients experience of the activity through repetition

Compensate

Things added in to compensate for any injury or decline SOC can help a patient to keep doing an activity or return to an activity that they have been avoiding or stopped as a result of their health status or physical decline. SOC can be used where the patient could get back to the activity but may need to adapt or augment how they do it. The key part of using SOC successfully is that the practitioner does not problem solve or generate the ideas for the patient, but guides them to generate their own ideas in each of the three areas, seeing the patient as the expert in the activity. Trying to avoid jumping in with solutions for the patient is important (‘have you tried x’, ‘have you considered....’). The practitioner’s role is to help the patient to try and think through ways to use the technique to get back to doing an activity as the expert in their activity. Arthur Rubinstein the famous pianist and his ability to continue playing into his later

life, despite losing dexterity in his hands for play at speed, illustrates how each element of the SOC model can be used. When asked for the secrets of his success, Rubinstein mentioned three strategies; First he reduced the scope of his repertoire, selecting down from thousands of pieces he would play and practice before, to just enough pieces to have a set list for a handful of live events he could rotate (an example of selection). As a result of selecting down to a smaller number of pieces, he therefore practised these pieces more than he would have before and noticed he became better at these through the additional practice of them (an example of optimisation) and finally Rubinstein compensated for the loss of dexterity, by creating the illusion of greater speed of playing for the audience by purposefully slowing down just immediately prior to playing the faster segments of his pieces, thereby giving his audience the impression of greater dexterity than was actually the case (an example of compensation). Clinical Example: A good example of how SOC could be used is if someone who was a regular gym user injured their arm. They would not be able to do the same exercises in the way they did before the injury. Through using SOC, they could consider ways to keep going to the gym, working around the injury, selecting suitable exercises. Repetition of those particular exercises more often may mean the person becomes better at them and they can maintain

their fitness, despite their physical limitation, thus optimising their experience. They may be able to compensate for the injury by seeing a personal trainer for a revised programme, wearing a suitable support or by having physiotherapy, for example. Practitioner: “I probably don’t know as much about golf as you do, so you will have to help me. Can you think of a few different ways you could still keep playing, but select down the activity of playing golf to make it more manageable, then we can discuss them and you can choose the one you feel best fits best for you. We want something that won’t decrease your enjoyment of golf long term by selecting it down, like you mentioned you wouldn’t enjoy coaching for example, it is thinking of ways that you may be able to still do certain aspects of it that will enhance your experience of it. For example, if a dancer was injured and had 100 dances they would normally practice but only 10-15 that get used regularly in shows, each dance would only get a limited amount of practice time prior to the injury. Post injury, if they selected fewer dances, say 25, each one would be practiced more, enhancing and optimising their experience. They might also compensate for the injury with a support bandage or physio sessions for example. Can you think of a way we could apply this to golf for you?.”

Values exercise

The values exercise is an optional scaffolding technique that can be used in a small minority of cases where a patient is really struggling to think of previously enjoyed activities as a result of long term depression or the negative filter of depression affecting their ability to recall more than one or two. It can also be used if a patient is no longer able to complete an activity that was previously enjoyed and it cannot be augmented with Selection, Optimisation and Compensation, for example if they have an injury or illness that prevents carrying out the same activity at all e.g. a loss of ability due to a physical health change or loss of a relationship that was central to the activity, the values exercise can be an optional activity to help generate ideas for the problem list. Due to both time and the fact the evidence that adding in complexity to the BA model, such as additional scaffolding techniques, is no more effective for the majority of patients, this should be reserved purely for these instances where additional help in creating the activities list and hierarchy is warranted. It is far preferential over giving the patient ready created prescribed lists of activities other people may enjoy. These are not recommended in BA. They do not generate 27

natural problem solving, are impersonal and can lead to the patient selecting activities that they are unlikely to engage with or keep doing. To use the values exercise, one activity can be used to generate further ideas that share similar values to the original activity. For example, if a patient used to enjoy cycling and was passionate about it, but can no longer cycle due to an accident or illness, the values they gained from cycling can be used to generate alternative activities. Whilst these activities may not be the same, they are far more beneficial than the alternative of not activating at all or doing activities that are unlikely to be something the patient wants to do or will engage with in the longer term. The practitioner should remember in BA activity is done for the sake of activity to break the cycle, not to generate any pleasure or reward initially. Just doing it is important. The task itself is not the focus, activating with a balance is. Practitioner: “So you mentioned you previously enjoyed cycling before your accident, but you are now unable to cycle for several months. I appreciate that must be very hard given how passionate you were about it” Patient: “Yes, I miss it a lot. I think about it a © Marie Chellingsworth (2020). The CBT Resource.

lot and it really gets me down to be honest” Practitioner: “I can imagine it would and I can see that is hard for you. While we can’t get you back to cycling when you are recovering from the accident for the next few months, getting back to doing activities that are balanced is important. I want these to be things that you can potentially would get something from though, even if they are not the same as we would be doing if you could still cycle. There is a way of doing this called the values exercise if that is something you would be willing to consider doing. It helps us to look at what you value from cycling, what you used to get from it and then to see if these values could be used to fuel ideas for any other activities that incorporate them in different ways for your hierarchy?” Patient: “Erm, yes OK then...” Practitioner: “To do that, we work out what it is you enjoy most from cycling when you were able to do it, what you valued most about doing it?” Patient: “Let me think....I suppose it is being outdoors maybe”

you get from cycling? What made you want to keep doing it?” Patient: “I liked the social side of it, we would all meet up, do a route and then have a drink afterwards, also the time away from home, it cleared my head of all the work stuff and that. Plus the views and scenery were pretty amazing a lot of the time” Practitioner: “Great, so we have a range of things there, getting outdoors, socialising with friends with that shared interest, getting time away from home to clear your mind and also nice scenery were all things you used to get from cycling,...” Patient: “Yes...I hadn’t really thought about it that deeply before, but yeah” Practitioner: “OK, so the next step is to think of some alternative activities that could put you into contact with those values for our list. Whilst not the same as cycling, they are things that you value, so using them as a way of building in activities can be really useful. Lets take the first one of being outdoors........What could you do that is an easier activity and outside...?”

Practitioner: ‘OK, so being outdoors is something we can write down. What else did © Marie Chellingsworth (2020). The CBT Resource.

The importance of homework and structure in LICBT

It should be remembered that homework is an essential component of all CBT based interventions. Research tells us that patients who are compliant with homework get the best outcomes (Coon & Gallagher-Thompson, 2002; Kazantzis et al., 2005) and that reviewing homework on the part of the practitioner increases patient compliance (Tompkins, 2002). As Laidlaw, (2015) states homework is not an optional extra to be used as and when it suits, but must form the start and end of every session. In addition, I would add that homework must always include a change method task(s) also, not just scaffolding, to be effective and in line with the evidence-base. Unlike high intensity CBT approaches, where  the session time is longer and somewhat more flexible; due to the time and evidence of Low Intensity CBT and the way in which it brings about change, the focus should always be on the change method tasks that the patient does between sessions. Effective Low Intensity CBT treatment sessions, whether delivered on the 29

telephone or face to face should always use a Plan It, Do It and Review it cycle structure. This means the focus of the first treatment session should be on making an effective plan for the change method inter-session task that the patient is to carry out between your sessions. Whether you use the term homework or inter-session task is entirely down to you and what your patient would prefer. Some patients with negative experiences of school may prefer the latter. Any potential internal things that may get in the way of their plan (things within them like confidence or understanding for example) or external things (like neighbours popping round or a friend calling on the telephone) that are outside of their control should be considered and problem solved in advance when homework setting, not resolved after the event, to maximise the potential of the patient carrying it out and having a good experience of the task. © Marie Chellingsworth (2020). The CBT Resource.

Review change method h/w learning

Plan next change method h/w

Patient will do change method h/w plan between sessions The patient should then go off and carry out their plan. The focus of subsequent sessions should be to review the change method tasks completed, problem solve any difficulties that have arisen and then make a new plan for the patient to go off and do more of the change methods of the protocol (and so on....). This structure does not and should not change in the context of working with someone with an LTC or an older adult. At times, the person we work with may not be used to a structured approach or may find it difficult to work within it. They may present challenges. When this occurs sessions can easily drift away from change method homework planning and reviewing into eclectic and nonevidence based support. If drifting from the agenda becomes problematic in a session, having already outlined the structure and way of working in the approach from the outset allows a gentle but clinically important reminder to be made such as: © Marie Chellingsworth (2020). The CBT Resource.

“As I mentioned when we first met, this is a time limited and active approach. To get the most from the sessions it is important we keep to the structure of reviewing how your change method tasks went this week, the tasks that work to improve your symptoms and meet your goals and us have time to make a new plan for next week. With that in mind, can I bring us back to......” OR “It is important to me that you get the most from the sessions and time that we have together. To do that we need to keep focused upon the tasks you did between session and make a new plan. I would like us to look at your homework next. It sounds important what you have told me so far. But to make sure that we have time to complete the agenda, can we move back to your worksheets and then if there is some time left at the end we can pick up this discussion if you would like to” 30

Manage endings from the beginning When working briefly, practitioners can find it challenging to raise the issue of discharge, particularly if the patient is socially isolated or lonely as a result of their difficulties. Patients may wrongly assume that treatment will go on for longer than the short-term nature of Low Intensity CBT. A clear discussion at the start of treatment about the structure and short term nature of the approach can stop this from feeling abrupt when it arises. Practitioners may also find it helpful to remind patients at each subsequent contact about the number of sessions before a review will take place (usually at session 4 of treatment for BA). Remembering the focus of LICBT sessions should be on the symptoms identified and improving these through the use of the change methods within the intervention is key to avoid drift and ensure outcomes for the patient. Practitioners cannot always solve every aspect of the patient’s situation through treatment and if the right intervention is targeted, often this is either unnecessary or indeed they may not be the most skilled person to do so. Trying to add more in to the treatment dilutes the change methods and optimal dose of treatment the patient gets in their LICBT. The use of signposting for practical difficulties such as debt or housing issues and referral to local community groups and befriending for patients’, whose social situations have not improved through the intervention for example, should be used to manage this. Relapse management to address early warning indicators of routine disruption, physical autonomic symptoms and changes in behaviour and thinking should be discussed. Differences between a lapse and a relapse and normalising mood fluctuations using the worksheets in the self help material should also be completed.

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Useful references on BA for depression Addis E, Martell CR. (2014) Overcoming depression one step at a time. Oakland: New Harbinger. American Psychiatric Association (Eds.) (2013) Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association. Amick HR, Gartlehner G, Gaynes BN, et al (2015) Comparative benefits and harms of second generation antidepressants and cognitive behavioral therapies in initial treatment of major depressive disorder: systematic review and meta-analysis. BMJ 2015; 351: h6019. Chellingsworth, M. (2020) Get back to being you with Behavioural Activation (BA). The CBT Resource. Chellingsworth, M., Laidlaw, K. and Davies, S. (2016) Low Intensity CBT with Older People. National curriculum for the IAPT Programme. Department of Health. Chellingsworth, M. (2017) Improve your mood with Behavioural Activation (BA). The CBT Resource. Chellingsworth, M., Farrand, P. (2015). How to beat depression one step at a time: Using evidence based low intensity CBT. Robinson. London. Ekers D, Richards D, McMillan D, Bland JM, Gilbody S. Behavioural activation delivered by the nonspecialist: phase II randomised controlled trial. Br J Psychiatry 2011; 198: 66–72. Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S. Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PLoS One 2014; 9: e100100. Jacobson NS, Martell CR, Dimidjian S. Behavioral activation treatment for depression: returning to contextual roots. Clin Psychol Sci Pract 2001; 8: 255–70. National Institute for Health and Care Excellence. Depression in adults: recognition and management (2019). London. Rhodes S, Richards DA, Ekers D, et al. Cost and outcome of behavioural activation versus cognitive behaviour therapy for depression (COBRA): study protocol for a randomised controlled trial. Trials 2014; 15: 29. Richards, D.,Ekers, at al. (2016) Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for depression (COBRA) A randomised, controlled, non inferiority trial. Lancet 2016; 388: 871–80. Published Online July 22, 2016 http://dx.doi.org/10.1016/ S0140-6736(16)31140-0 Shinohara K, Honyashiki M, Imai H, et al. Behavioural therapies versus other psychological therapies for depression. Cochrane Database Syst Rev 2013; 10: CD008696. Wiles N, Thomas L, Abel A, et al. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial. Lancet 2013; 381: 375–84.

Marie Chellingsworth The CBT Resource ® Marie is a renowned CBT and IAPT consultant, academic and author. She is the Founder of The CBT Resource and an invited Subject Matter Expert (SME) for a number of digital therapeutic and mental health services. She is a co-author of the IAPT PWP curriculum and high and low intensity CBT with older people curricula as well as many resources for patients with anxiety and depression. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments and ensure practitioners are supported to get optimal outcomes through CPD training and supervision. She has over twenty years experience in the field, publishing a wide range of CBT self help packages and national training for practitioners supporting people with these difficulties. She has worked with UK national bodies and the IAPT workforce and training groups within the Department Of Health to maintain standards for CBT and IAPT based approaches and was Consultant to the successful implementation of the Australian IAPT programme. Prior to developing The CBT Resource, she was Executive Director of Evidence Based Programmes at UEA and Senior Lecturer and Director of Training at the Universities of Nottingham and Exeter. Her passion for CBT and working in this field first came after hearing a song called Howard Hughes (a B side of a band called Ride in 1992!). Outside of work she loves music, interior design, gardening and spending time on the local beaches and forests with her Irish Setters and with family and friends. www.thecbtresource.co.uk

Andy Poplar [Vinegar & Brown Paper]® The photographs of etched glass and objects throughout this programme are the work of Andy Poplar from [vinegar & brown paper]® ideas etched in glass. Special thanks and credit goes to him for enabling us to use these images. An award winning advertising creative, he set out to mend his head with [Vinegar & Brown paper] after his own experience with anxiety and depression. At the heart of Andy’s work are his reflections upon his own experiences that led to his career change into etching glass. As [vinegar & brown paper], Andy has spent the last 8 years taking vintage or iconic items of glassware and bringing them to life with the tools of typography, wit, word-play and a slightly askew way of looking at the world. You can now find pieces of [vinegar & brown paper] on bookshelves everywhere, from York to New York (and a much happier man too). You can find more of Andy’s work on his website and his Facebook and Instagram pages on the links below. Website: www.vinegarandbrownpaper.co.uk Instagram: instagram.com/mendyourhead Facebook: facebook.com/mendyourhead