Overview of Behavioral Activation

Presenting BA-M's Model

The Session 1 outline (covered in the next lesson) presents specific language for use in the first session when presenting the treatment rationale. Here we discuss the general idea behind this rationale, presented typically as the “2 circles” model. This is taken from a model of BA that has previously been culturally adapted (Kanter, 2010) and was found to be acceptable for use with Muslim clients in our own pilot study (Mir et al., 2012).

The 2 Circles Model

Circle 1: Difficult Life Events

Clients may present in therapy with a variety of difficult life events, problems, daily hassles, stressors, and the like. Our fieldwork and existing studies showed that within Muslim communities these difficult life events may be influenced by:

• high rates of disability, long-term illness and infant deaths (National Statistics, 2004; Department of Health, 2008)
• high rates of poverty, unemployment and poor social mobility (Platt, 2005; 2007)
• financial problems (Chew-Graham et al., 2002; Klainin and Arthur, 2009)
• discrimination in a wide range of areas that affect health, such as employment, housing and education (Richardson and Stone, 2004)
• media representation that promotes hostile and stereotypical images of Islam and those who follow its teachings (Al-Issa, 2000; Whitaker, 2002)
• for migrants, difficulties in acculturation (the process of adapting to the cultural norms of the host country) when norms conflict with those of their cultural background (Askari, 2003). The social change can involve experiences of discrimination (Al-Issa, 2000) and role conflict, particularly where migration is involuntary as in the case of refugees (Aziz, 1999; Askari, 2003). In one study older adult migrants were more likely to be depressed than younger adult migrants (Ebrahimian, 2006)
• family problems, isolation, or limited English, all of which, for example, affect women who experience maternal depression, particularly if they have migrated for marriage (Small et al., 2003). Living within an extended family can be a stressor for daughters-in-law (Fazil and Cochrane, 2003) but beneficial for the mental health of children and grandparents (Sonuga-Barke and Mistry, 2000). Family and community pressures relating to reputation or family honour may also contribute to stress, particularly for women (Al-Issa, 2000)
• dependence on khat, a culturally specific drug, is associated with depression in some African and Middle Eastern Muslim communities (Awas et al., 1999)

In short, there are a wide range of potential stressors for people living within Muslim communities in the UK. The first stage of BA involves determining collaboratively with the client the specific nature of the problems and stressors causing low mood. Some clients may report just one or two discrete problems or losses, such as death in the family, divorce, or recent unemployment. Others will report on the accrual of multiple smaller hassles and stressors. Others will have been living in chronically stressful and deprived environments for so long that they will at first have no losses to report on, because nothing new has happened or changed in quite some time. Regardless, undoubtedly there will be problems, and it is the job of the BA therapist to emphasize that many of the symptoms of depression make sense given these problems.

In the first session of BA-M, the therapist should develop a list of these difficult life events, write them down and share them with the client. The therapist may call them “difficult life events” and draw a circle around them.

Circle 2: Common Responses

It is a natural human response, when bad things happen (either major events, the accrual of smaller events, or a combination of these), to feel bad and to become passive. In BA, these are called common responses to emphasize that they are common and that the client isn’t weak, unusual or mad for having them. The client will feel sad, down or depressed. The client may cry more frequently or experience increased irritation. The client may feel tired, lethargic, lacking in energy. The client may feel that nothing is fun anymore. The important point for the BA therapist to stress is that these responses are common and make sense. Anyone would feel this way given the client’s situation.

Some common emotional responses are likely to include: anger and irritability, despair, feeling depressed, shame, sadness, physical symptoms, feeling down, grief reactions, crying more, stress, and fatigue.

[Production note: in the source version, this section is a drag-and-drop exercise sorting which items count as common emotional responses to difficult life events and which do not (e.g., happiness, gratitude, excitement, curiosity in activities and motivation are NOT counted as common responses to difficult events).]

The client may also demonstrate a range of behavioural common responses to difficult life events. These include:

• Passivity
• Avoidance
• Not wanting to go out any more
• Staying in bed
• Sleeping too much
• Calling in sick to work
• Withdrawing from friends/family
• Stopping religious activities such as prayer, going to the mosque or reciting the Quran
• Stopping housework
• Stopping looking for work or pretending to look for work
• Smoking, using drugs, overusing prescriptions meds
• Filling every minute of the day to avoid facing problems
• Watching television
• Lashing out at others including family and children
• Eating too much junk food
• Trying to kill oneself
• Acting like life is already over

It is the therapist’s task in BA to understand the client’s common responses to the difficult life events, whatever they are, and validate and normalise them. If it becomes clear that religion is important to the client, it can be helpful to explore the degree to which the client sees this way of thinking about depression as compatible with their faith. The client’s understanding of how Muslims are encouraged to respond to difficulties may be helpful for this discussion and some relevant Islamic teachings are contained in the Client Booklet that accompanies the therapy manual for BA-M. Some ways in which the manual can be used to draw parallels between the BA approach and Islamic teachings are described later in this course. For example, drawing on a religious framework may be an effective way to help some clients feel that it is normal to feel sad when difficult life events happen.

In the first session, the therapist may develop a list of the client’s common responses, write them down, and label them “common responses.” The therapist may circle the list and draw an arrow from the difficult life events to the common responses to show that they are an understandable response to the events.

Putting It All Together

When clients respond to difficult life events with hopelessness and passivity, it makes problems worse and starts the cycle of depression. It is important for clients to see this pattern.

Example of the 2 circles model — Relationship problems: some families may have specific expectations about the roles that family members should fulfil and these can clash with what individuals feel capable of or want for themselves, leading to tension and the breakdown of relationships.

Acculturation Issues: some Muslims have migrated to the UK, particularly older people, young people who came for marriage and refugees or asylum seekers. Low income, limited ability in English and recent migration can all contribute to problems with acculturation. Clients may be fearful of mainstream society and/or of being forced to acculturate in ways that are inconsistent with their values, beliefs, skills, and knowledge. In addition, clients may be being paid very low wages for working extended hours. Many clients simply do not know how to solve these problems, do not have the necessary skills, and do not recognize the time commitment involved. Failure to successfully acculturate and overcome these multi-faceted problems leads to frustration which turns into hopelessness as the length of time in the U.K. without solving these problems continues. Thus, passivity and hopelessness are also seen as common responses.

Discrimination: [Production note: the worked example for this theme was not fully captured from the source.]

Modifying the Model to Focus on Avoidance of Bad Feelings

In some cases the therapist may observe that the client is very focused on not feeling bad, and many of the common responses are attempts to avoid the bad feelings. Feeling bad is hard and it is natural to not want to feel this way. The question is, what does one do to not feel this way? It is natural to do things to avoid feeling bad, even if these things have a cost. When feeling upset we go to sleep. When feeling like crying we avoid going to places where crying is likely. We may avoid social situations entirely or attend passively and without spirit. When feeling badly enough, it is easy to give up, become hopeless and passive.

According to BA, it is often this secondary response, of avoidance and passivity, which we may call getting stuck, to the initial common response that causes a spiral into depression.

Another way of thinking about getting stuck is that clients may be focused on short term solutions to problems, which are about just feeling better as soon as possible, versus long term solutions to problems. The therapist should explain that activation will be very focused on the things that the client has been avoiding doing, the things that are hard to do on one’s own and one would continue to avoid if left by one’s self. In addition, activities that will help the client feel more positive and resilient will also be a focus of activation.

In these cases it may be helpful to distinguish common emotional responses from common behavioural responses in the model, resulting in 3 circles, with the emotional responses labelled “common responses” and the behavioural responses labelled “getting stuck.”

Example of the 3 circles model: consider a client whose primary response is anger and irritability. This is a common response, and the key here is how the client responds behaviourally to feeling angry. What does the client do? Arguing with his wife would be a behavioural response that would go in the “getting stuck” circle — not the “common responses” circle. (In the source version this is presented as a multiple-choice quiz.) The client could be asked, “When you argue with your wife, does it help the problem or make it worse?” and the therapist and client would work at developing more positive responses to anger that help solve problems rather than make them worse.

Structure of This Manual

The session plans for delivering BA-M therapy include references to sections later in the manual that the therapist will need to read and understand in order to engage appropriately with Muslim clients, particularly those for whom religion is important.

These later sections cover understandings of depression within Muslim communities, the therapeutic relationship promoted in this therapy, how to discuss religion, how to schedule activation assignments and use the Client Booklet, and how to involve family members and make use of community resources.

Companion Video Transcript

Behavioural activation has a long history dating back to the 1970s. It evolved out of a behavioural model of depression and all variants of behavioural activation have maintained a primary focus on using behavioural techniques to schedule new activities. As behavioural activation has evolved, the focus of activity scheduling has shifted from simple, pleasant and enjoyable events to activities that are consistent with a client's life goals and values, active problem solving, functional alternatives to avoidance and rumination. Activities that bring a sense of mastery or accomplishment and other activities that do not necessarily bring about feelings of pleasure or enjoyment, but are still functionally important to the client.

Over the years, behavioural activation has received a wealth of empirical support, documented in three meta analyses. In a systematic review of randomised trials, behavioural activation was comparable to cognitive behaviour therapy in reducing symptoms of depression at post treatment and follow up. Most evidence of effectiveness has been developed in populations that have not been diverse in terms of faith, identity, or ethnic background. However, this manual has been piloted with Muslim clients, and the pilot study provided evidence that a focus on behaviour is also acceptable and perceived as helpful within this population.

As presented to clients, behavioural activation has a very straightforward rationale. People are more likely to become depressed when there are more difficult events in their lives. Difficult life events may be major losses like the end of a relationship, the loss of a job, or a move to a new city. Difficult events may be interpersonal difficulties, including a lack of friends or conflicts with friends or family members. Difficult events may be daily hassles arising from a promotion that leads to too many responsibilities, inability to pay the bills, confusion about how to use public transportation and experiences of racism or discrimination. The more difficult events one experiences in one's life, the more likely one is to become depressed.

When a client becomes depressed, he or she gives up, gets stuck, becomes hopeless, becomes passive and inactive in life. He or she stops putting in real effort to solve problems and stops doing activities that used to be pleasant, meaningful, and enjoyable. Individuals may even stop taking care of themselves, showering and brushing teeth or getting out of bed. All of these changes may result in the depression getting worse, which starts a vicious cycle of depression. Behavioural activation focuses on the difficult events that cause people to get depressed in the first place and on helping people get active again in life to break the cycle of depression. Behavioural activation uses behavioural techniques to activate clients, to solve problems, not giving up in the face of seemingly overwhelming obstacles, experience pleasure and mastery in what one does, and stay committed to active lifestyles in support of one's life goals and values.

When the client understands this cycle, the therapist can then discuss what they are going to do about it. Specifically, behavioral activation directly targets how the client has become stuck, passive, and inactive. The goal is to help the client activate behaviors that proactively address the initial difficult life events. Stay active, solve problems, get out of bed, and apply for jobs. Start praying or going to the mosque, force oneself to interact with others, call the friend with whom one had an argument, do the dishes that have piled up in the sink.

The therapist's job is to collaborate with the client to identify the difficult life events and the common responses and then collaboratively design activation assignments that are attempts to solve the initial problems rather than the common responses. Activation assignments will be formulated in the context of what is important to the client and there should be early discussion of the client's values so that these can be built into the goals that are designed as part of the therapy.