Session plans

Session Plans for BA-M

Session 1

Step 1 — Before the Session

Read the sections of the manual about Discussing Depression, Treating Muslim Clients with Depression and General Issues when Conducting BA-M to prepare yourself for issues that may arise.

The development of a relationship on the client’s terms is an important first step for engagement and trying to impose a specific model or therapy framework on interaction too soon will hamper this. Initial sessions should therefore focus on understanding what is important to the client and establishing a good relationship.

Ensure the therapy room will be comfortable for the client.

Step 2 — Language

Ask the client what language he or she would like to speak in, if necessary. Ask in the language the client has been using.

Step 3 — Review Screening Measures

Screening measures used in this therapy are the Values and Goals Assessment (see Appendix), which is used at the beginning of therapy and PHQ9, GAD7, which are completed before each session and which were seen as acceptable to Muslim clients during our pilot study of this manual along with the Behavioural Activation for Depression Scale (see Appendix 1). The purpose of the measures should be explained to clients and therapists should check that the client understands how to answer questions and provide support where necessary.

Our initial fieldwork indicated that some clients may feel offended about being asked questions relating to suicide, because this is forbidden in Islam. However, feedback from the pilot study showed that clients accepted this was a reasonable question. It is routine in the PHQ-9 screening questionnaire used with this manual and therapists we spoke to dealt with any negative reactions by acknowledging that, whilst in most religions suicide is a sin, having suicidal thoughts is normal and this would not make someone a bad person. The therapist can highlight that these are questions that everybody is asked, regardless of their religious beliefs, so that if there are any suicidal thoughts, they can talk about these. Check for suicide risk.

Step 4 — Talking About Client’s Life Story

Begin the session by getting to know the client, the client’s life, the client’s story. For some clients it may be helpful to suggest that the client does not have to give away family secrets or divulge what he/she does not want to. As you listen to and ask about the client’s story:

• be warm, validating and responsive (see The Therapeutic Relationship);
• try to obtain information to guide future activation assignments and think about potential activation assignments that can be given to the client at the end of the first session;
• collect information so you will be able to link the client’s story to the “2 circles” model later in the session;
• discuss what the client sees as the cause of the depression/feeling the way he/she does (see “Discussing Depression”).

Difficult life events: learn about the difficulties that have been occurring in his/her life, both currently and historically. Take your time with this and try to cover all the important past and present issues. Write these issues down as a list to show the client later in the session. Call them “difficult life events.” Consider the list of difficult life events highlighted in Presenting BA-M’s Model of Depression.

Common responses: listen to and ask the client about his/her responses to the life events. How has the client been feeling or responding? Listen for and ask about ways the client has become stuck.

Take your time with this and write the responses down to show the client later. Call this list “common responses” or something like that.

The important point is that when people have these difficult life events, they naturally feel this way. The way the client is feeling is not an illness or a weakness. It is an understandable response to life’s difficulties.

Really emphasize how the responses make sense given the client’s difficult life events. THIS POINT CAN BE STATED REPEATEDLY. If there is one thing we want the client to get from this session, this is it. You can say that depression does not mean the client is going mad, or that there is something wrong in the client’s head. It is understandable.

Step 5 — Summary of Model

Show the client the 2 circles with the lists you have made. Do this to explain the model but also to express compassion and give the client the sense that you have been listening deeply and empathically to the client’s life story.

Express to the client that this treatment is about getting active in life again. It is about taking action steps to solve problems, rather than avoiding, feeling overwhelmed, and shutting down to avoid feeling so terrible. The focus of the treatment is on coming up with action plans and taking action, to help the client start doing things that he/she used to do before he/she became depressed, and things that the client doesn’t have the energy to do. The goal is to get the client back on track in life.

Tell the client this is an active treatment, it will require work. The key is to do things differently in life. Treatment will be about figuring out what needs to change and how to change it. This will be done by the therapist listening very carefully to the client’s story and then the client and therapist together will come up with plans for what to do differently during the week. For clients who have indicated that religion is important to them it may be helpful to draw on the parallels between BA’s focus on activity and the amount of activity contained in the five pillars of Islam (see Client Booklet).

It is key to the model that activation will lead to improved mood and that the client cannot afford to wait until he or she feels better to start solving their problems.

Step 6 — Ask for Feedback About the Model

Discuss with the client what he/she likes and doesn’t like about the approach. Discuss with the client what makes sense about it. You may ask the client to state in his/her own words what they are understanding.

Carry out a Values Assessment using the forms/picture at Appendix 2. The therapist should use this form as a starting point for assessing what is important to the client. The assessment is a key part of the therapy and should not be rushed. Filling in the form can be a homework assignment if time is running short and you feel the client would be able to fill in the form on their own. Many clients in our pilot study preferred an oral discussion of the issues contained in the form but a written/picture version of their assessment should also be provided to take away at the end of the session as a reminder of what they are aiming to achieve through therapy (Appendix 2).

Tell the client that his or her own values and goals are extremely important in deciding what kind of activities will help. Check that he or she understands the purpose of the assessment and how it will influence therapy. The therapist should use the values identified by the client to move very rapidly to goals that can be scheduled as concrete actions. Avoid a vague, unstructured discussion of the client’s values that is not linked to specific actions.

It is extremely important to accept the client’s values, including religious beliefs, in a non-critical way, in order to develop trust and open discussion. Therapists who are from a Muslim background themselves should try their best to create a safe space for clients to say that religion is not important to them, if this is the case.

Evidence of ‘negative religious coping’ or ambivalent/hostile views of God will also need to be addressed in therapy if they play a part in maintaining depression. Strategies for how to do this are included in the section on Discussing Religion.

Whilst religion is not a central aspect of identity for every Muslim person, Islam will have formed part of the upbringing of most Muslims. A client’s relationship with God is, therefore, likely to feature in some way for the majority of people, including people who are struggling to make sense of their identity and people who do not appear to be overtly religious. In our pilot study this assessment was found helpful by people who were and were not practising Muslims.

Step 7 — Set an Initial Activation Assignment

It is always a good idea to give the client an initial activation assignment or two at the very first session, to set the tone and get the client moving quickly. As you were listening to the client’s story and discussing their values and goals, ideas for activation assignments may have occurred to you. If they did, discuss them with the client.

Discuss these initial assignments as you would any activation assignment in BA (see the section on “Scheduling Activation Assignments”).

Step 8 — Discuss Coming to the Second Session

Tell the client how long the treatment will last (our research was based on up to 12 sessions of 50 minutes but some clients may need more or less than this). Tell the client that you expect that he or she will have started to feel better well before the end of therapy but the goal of treatment is not just to feel better. You will be teaching the client a new skill—the skill of learning how to respond to difficult life events and to feeling bad with action steps so s/he does not get stuck. It takes time to learn this skill so ask the client to commit to at least 6 sessions even if they start to feel better immediately.

Tell the client that it is very important to come to sessions, and ask how they feel about coming weekly.

Discuss the next session time. Ask if there are things that will get in the way of the client coming to next session? Problem solve barriers to coming to the next session.

Let the client know how s/he can get in touch with you if necessary in between sessions.

Step 9 — Session Review

Make sure you leave time to review the session. This should not be rushed, especially in the first session.

Ask client for feedback about today’s session. What do you think about our approach? Are there things you think will be particularly helpful? Unhelpful? Does the approach fit with the client’s beliefs and values?

Address and problem-solve any negative reactions the client might be having.

Step 10 — Conducting the First Session When You Are Short of Time

The most important elements of Session 1 are: listening to the client’s story, explaining the BA model and setting a homework assignment. If there is no time to do more than this then other parts of Session 1 can be carried over to the following session.

The essential elements of the first session can be covered by breaking the session up into three parts – first, ask the client ‘What brought you here today?’. This will cover the first circle (of the 2 circle model). Then follow this by asking how the client responded to the situation/problems that resulted in them seeking therapy – this covers the 2nd circle. And finally acknowledge that you haven’t been able to cover everything, but based on what you have learnt about the client try to set one or two simple activation assignments.

Optional Issues for Session 1

Initial activation assignments: where the Values Assessment has shown that religion is important to the client, religious behaviours should be treated like any other to be activated in BA and the therapist should think about issues of shaping, scheduling and structuring the behaviour. It will be useful to discuss early on how much clients would value building religious activities into their assignments and what they would consider an achievable level of religious practice.

The Client Booklet is intended to be a resource for clients who wish to draw on their faith as a support and includes Islamic teachings that they may find helpful. The booklet should not be offered immediately to clients but can be suggested to those who have referred positively to religion in relation to their values, beliefs or activities. The therapist might say ‘I wonder if you would find this booklet of any interest? It’s a collection of quotes from the Qur’an and Hadith that some people have found useful. You may or may not find it helpful and we could perhaps discuss what you think about it next time we meet’. The Booklet contains space for clients to add their own quotations and any teachings they have found especially helpful and clients should be encouraged to note down their responses to the teachings.

For clients using ‘negative religious coping’, who may have ambivalent or hostile views of God, the therapist could explain that positive ways of thinking about one’s relationship with God can help people overcome depression. Depending on whether the therapist thinks it would be useful, the Booklet could be introduced as an alternative way of drawing on religious beliefs and the therapist could explore the client’s response to reading the Booklet as an activation assignment.

If clients need to learn how to do a particular activity (eg prayer) help them identify an individual or group they can approach for support. See the Useful Resources at Appendix 9 for examples of the kinds of organisations that could be helpful to clients.

Activity monitoring: explain the activity chart (Appendix 3) as a way to get a sense of what the client’s daily activities look like, so we can begin to figure out what needs to change. Explain that clients should complete the chart at the end of each day. Depending on the client, you can also ask the client to rate his/her mood during the activities (using a scale of 0-10), or mastery/pleasure during the activities, or anything else that you think would be useful to know.

Ask clients if they will be able to complete the chart? What might get in the way? Try to come up with solutions to potential barriers. Be creative. For example: individuals without literacy skills can use pictures or work with a friend or family member to record their activities and the rating they give verbally. If there are many other demands on the client’s time suggest again that a friend or family member be asked to help remind or encourage the client to fill in the chart at the end of each day.

Discuss where clients are going to keep the chart (on nightstand, on refrigerator, by tv, etc.). Discuss telling another family member about the assignment. Possibly discuss rewarding self for completing the assignment (can they do the chart and then watch tv, versus putting on the tv immediately?).

Phone call activity monitoring: one possibility is to have the client call you and report the activities over the phone. This could be done twice a week. Ask the client to call at different times so there is a good sampling and representation of important time periods. The client needs to make the call, not his/her spouse or son or daughter, etc. It may be a good idea to tell a family member that the client will be making the call.

If the client has been prescribed medication, or is scheduled to see the psychiatrist: explain to the client that taking medication may be helpful but people are more likely to relapse if they stop taking it. Discuss any concerns about medication, for example, clients may have concerns about side effects or whether the ingredients in medication are halal ie from sources that are allowed by religious rulings. Medicines that contain gelatine, glycerine and other animal-based ingredients or alcohol can be seen as haraam ie forbidden and not taken as a result (Sattar, Ahmed et al. 2004). It will be helpful to discuss whether any alternative medication can be prescribed and what to do if this is not available. Explain that the important thing is to work out how to take action and take concrete steps to help deal with depression, and get started solving problems in addition to taking medication.

Family involvement: tell the client that it is up to him/her how much family can be involved but that it may help the client take action. Tell the client that family members can be invited in to sessions. Ask the client how he/she feels about inviting family members to attend future sessions.

If it is important to get a family member on board to ensure a client’s continuation with therapy, the therapist should get the client’s permission and call the family member him or herself rather than relying on the client. The therapist should really try to sell the treatment, convincing the person to come: “Would you be willing to come to our session next week? It would be so important for you to come to a session and learn about what we are doing.”

If the client is interested in bringing a family member in to treatment: discuss with the client his/her relationship with this family member. Is this person supportive or part of the problem? If this person is clearly supportive, schedule to bring the family member in as soon as possible. Try to get the family member in for the next session. If this person is not supportive, tell the client that you will need to figure out how to get the family member to be helpful, and it may be an important aspect of treatment.

Session 2 (Family Not Present)

If the Client Booklet has been given to the client, discuss any teachings they have found especially helpful. The techniques and tools of BA may be specifically used to help clients integrate any teachings from the Booklet they have found helpful with the treatment for depression. For example, the five or ten teachings clients think are most important can become “activation assignments” and the therapist can work with the client to get him or her active in these ways.

If a client has an ambivalent or hostile view of their relationship with God and did not find the Client Booklet helpful, the therapist may need to consider other resources that could help. For example, the therapist could collaborate with someone from within the Muslim community who has the religious authority to provide alternatives to unhelpful beliefs (see Appendix 11).

If the client did not complete the homework: first, assess the barriers to completing the homework, problem-solve barriers creatively, and stress the importance of completing future assignments. Reconstruct the basic activities of each day focusing on possible activation and avoidance examples and then follow the above instructions.

If appropriate, review possibility of later family/friend involvement. Family involvement does not need to involve attending sessions. Again, creativity is encouraged.

Assign activity chart and give activation assignment: add mood during the activities (0-10), or mastery/pleasure during the activities, or anything else that you think would be useful to know to the activity chart if appropriate. Only do this if the client successfully completed the activity chart the first time. If not save it for later (BA assignments should always be graded). Devise activation assignments that have a good chance of being accomplished, but will still be meaningful for the individual client. For client A this might mean going for grocery shopping and a 30-min jog and for client B this might mean simply leaving the house and walking around the block.

Discuss barriers to completion of assignments: ask client if they will be able to complete this chart? What might get in the way? Try to come up with solutions to potential barriers. Be creative. Discuss where they are going to keep the chart (on nightstand, on refrigerator, by television, etc.). Discuss barriers to completing the activation assignment. For both assignments, ask, “What can we do that will make it more likely that you will be successful?” Then do it. Discuss telling another family member about the assignment. Possibly discuss rewarding self for completing the assignment (can they do the chart and then watch TV, versus putting on the TV immediately?).

Homework: activity monitoring; activation assignment.

Session review: make sure you leave time to review the session. You need time to address and problem-solve any difficult reactions the client might be having. Ask client for feedback about today’s session. What do you think about our approach? Are there things you think will be particularly helpful? Unhelpful? If religion appears important or helpful to the client, ask whether he or she would be interested in continuing with the Client Booklet and discussing this with you in the following session.

Coming to next session (see General Issues when Conducting BA-M): tell the client that it is very important to come to sessions. Are there things that will get in the way of the client coming to next session? Problem-solve barriers to coming to session.

Session 2 (If the Family Is Present)

Step 1: review the sections of the manual on Family and Community Involvement and, if the client has listed religion as a value, the section about the Client Booklet. Overall purpose: to learn how the client interacts with the family and work out ways for the family to assist with treatment. Ask the client to complete PHQ9, GAD7 and BADS-SF measures.

Step 2 — Meet individually with the client: try to meet with the client individually for a short time before bringing in the family. This will allow you to determine any information that should not be shared and particular family members that may or may not be helpful collaborators. However, be flexible (you may have to do the whole meeting with the family members present). Describe the purpose of the meeting. Review the previous session — this time will also allow you to review the activity chart and any other homework assignments from the previous session (often the client will not complete the first assignment and may feel embarrassed if this is discussed in front of family members).

From the activities listed in the chart, you may be able to gauge how important religious activities are to the client, for example, if a person begins the day by observing the pre-dawn prayer or tries to remain in a state of purity by performing ablution this will indicate an important position for religion in their life. If the Client Booklet has been given to the client, discuss their reaction to this and any teachings they have found helpful.

It is very important that it is the client’s choice how involved the family is. Make this clear while meeting alone and ask the client if there are particular areas in which he or she does not want the family to be involved.

Step 3 — Discuss treatment with the family: describe the purpose of this meeting. Review the model of depression with family. Focus on common responses (2nd circle) to make sure the family understands that what the client is feeling makes sense. Make it clear that we do not think the client is mad and emphasise that feeling depressed following difficult life events is understandable. Emphasize that it is good that the client is in therapy. Let the family know that treatment takes time (so be patient) and enlist the help of the family in encouraging the client to come to session every week, even if they are feeling depressed. Let the family know that they can be a big part in helping the client get better.

Step 4 — Use the family’s inside knowledge to assist in your assessment: ask the family what the client was like and what he/she enjoyed doing before becoming depressed. It is possible that the client will overlook important areas for activation. Ask the family in what situations the client seems most depressed and least depressed.

Step 5 — Enlist the family’s help in treatment: give the family a rationale for and enlist their help in encouraging the client to be active (even in very small ways) while feeling depressed or not having the energy. Let the family know that the loving response is not always the response that will help the client. For example, taking over all of the client’s household chores may function to maintain depression. Use the information gathered in this session and Session 1 to suggest interventions for family members. It may be particularly useful to involve supportive family members in the completion of homework assignments. For example, you could ask a family member to discuss the homework for the week with the client each week after the session and provide reminders, encouragement, and facilitation (e.g., transportation). Make sure the family does not badger or criticize the client. Get permission from the client for the family to ask about completion of homework and provide reminders. Schedule family member’s asking about homework to avoid badgering (e.g., Wednesday evening the family can check in with client).

Step 6 — Give homework: activity monitoring; activation assignment (involve family if appropriate). It is often helpful to provide the client with a small calendar or day planner to facilitate scheduling activities.

The techniques and tools of BA may be specifically used to help clients integrate any teachings from the Client Booklet they have found helpful with the treatment for depression. The extent to which religious activities are suggested as a resource for dealing with depression will need to match the client’s level of religiosity to avoid inducing guilt at not being able to fulfill assignments. However, the absence of religious activity may be a consequence of feeling depressed and it should not be assumed that clients who do not mention religious activity would not be interested in these. Feelings of guilt about not fulfilling religious practice can be discussed in terms of helpful behaviours to address this (Andreasen, 1972).

Step 7 — Discuss barriers to completion of homework: ask client if they will be able to do their homework assignments? What might get in the way? Try to come up with solutions to potential barriers. Be creative. Discuss family members’ role in helping with completion.

Step 8 — Coming to the next session: remind the client and family members of the importance of coming to sessions. Are there things that will get in the way of the client coming to next session? Problem-solve barriers to coming to session. Involve the family where necessary.

Step 9 — Finish session alone with client to review session: make sure you leave time to review the session. You need time to address and problem-solve any negative reactions the client might be having, especially reactions to having the family in the room. Ask client for feedback about today’s session. If religion appears important or helpful to the client, ask whether he or she would be interested in continuing with the Client Booklet.

Sessions 3–11

Sessions 3 to 11 should follow the basic structure of BA, which is: (1) review screening measures; (2) set agenda; (3) review homework and activity level since last session; (4) develop new activation assignments as homework; (5) other agenda topics; (6) session feedback including client review and questions.

Activity charts or calendars may be used to track and schedule activities and the Activity Hierarchy (Appendix 4) and Activation Homework Sheet (Appendix 5) may be used. Therapists should pay attention to the level of difficulty of the tasks to be assigned, and how avoidant/scared of the task the client is, and collaboratively work with the client to schedule tasks that are graded in terms of difficulty and fear level. The important thing in earlier sessions is that the client experiences some mastery and success with the tasks, so they should not be too difficult. It is also important for the therapist to save a few minutes at the end of the session to review the session and ask for client feedback about what was useful and not useful.

If the client has been offered but not taken up the option to involve family members, this should be raised again in a later session. Our research showed that some clients who would have found this helpful did not realise or remember they could include family members in therapy and would have valued a reminder that this was possible.

Final Session

Before the session: review ALL progress notes on the client.

Step 1 — Overall purpose: review progress and complete “Staying Active Guide.” The therapist and client should review the client’s progress. Clients often do not remember how depressed they were at the beginning of treatment and how much progress they have made. It may be helpful for the therapist to review all the progress notes before the session, so the therapist will be able to remind the client of details from the past. Focus on how learning to take action has resulted in a better life.

Complete “Staying Active Guide”: complete the form at Appendix 6 collaboratively with the client. Ask the client the questions on the form but help shape the responses to be as appropriate as possible. The form is for the client to keep in an important place and review weekly. Make a copy of the form at the end of the session. This will be helpful if the client calls for help in the future, or if the client loses the form the client can call you for another copy. You may want to add a personal note to the end of the form with your name and phone number.

Step 2: review PHQ9, GAD7 and BADS-SF. In addition, it may be useful to graph the client’s scores from over the course of therapy to highlight gains.

Step 3: set the agenda.

Step 4: review homework. As in all sessions, this session should begin with a review of the previous week’s activation assignments.

Self-therapy: the therapist could encourage the client to schedule “self-therapy” sessions once a week. In these sessions, the client would continue the work of looking at his/her avoidance and activity, and schedule new activities, including religious activities if these have been helpful. Then, the next week the client should review the previous assignments. In other words, the self-therapy sessions should mimic the real therapy that is now ending.

Session Demonstration — Transcript 1

[Production note: transcript of a session-demonstration video from the source, showing a therapist and client discussing barriers to a prayer-scheduling activation assignment.]

So well done for coming back to your therapy today. Um so last time we covered a bit of activity scheduling and we were looking at your values and incorporating some of the behaviors that you've stopped doing for the value of being a Muslim and following Islam into an activity schedule that you could try out for the week. Mhm. So, I'm I'm wondering how that felt and how it went. Um, it was okay. I mean, um, it just felt a bit upsetting in a way that I can't do what I could do before and it started to become really hard to do to do some of the stuff I think. and you know I don't understand kind of feel I feel I feel worse like yeah okay well I'd like to start by saying welding for having a go I can see here you've brought your activity schedule and you've definitely um tried out the technique of scheduling and new behaviors but I also want to comment on it does sound like it's been difficult for you and that's quite common when people have learned mood and depression. We're still at the early start of therapy, so we're trying to break some cycles, okay, you might have found yourself in. So, looking at some of the things that you've told me from before when you've avoided some of these activities, and I can see sometimes you've um managed to do the the praying as you've scheduled and sometimes you haven't. Yeah. What do you feel like when you've managed to achieve that goal that you've set out on that day? How does that feel? It feels good in to some extent I'd say. But then I also kind of feel like worse when I'm not doing like have you seen here the morning prayer. So just before the sun rises the fudger prayer. Mh. Um I've not been getting up for that. and I feel worse. And I don't know why because you know I'm praying to Allah like like wake me up in a way but I'm not waking up and that just gets me feeling quite even more down I'd say. Understand? So let's look at that and unpack that together a little bit. So I can see um you've struggled. It must have been uh really difficult to get up for those morning prayers really early in the morning. Yeah. And just to be a little bit kinder kinder with yourself, we know that some of your symptoms are struggling to get off to sleep at night at this moment in time and uh we've been talking about your symptom of feeling fatigued a lot. So that would fit with why, you know, it is so difficult to get up in the morning. And I wonder if it's something that we should take into account at this moment in time. It might be easier to work on incorporating some of the afternoon prayers um and not overwhelming yourself with this morning prayer at this moment. So the reason why I'm saying that is uh what can happen with um low mood treatment is that once you start something it can feel really really difficult to get it back into your daily routine. But once you start achieving your goal and it becomes more automatic, it can feel like a little bit easier. You can have more energy with that. And what you're actually doing is placing the things that you value on the outside of your life and and trying to focus on achieving those goals. And that can actually make you feel better on the inside of your body. So we call it the outside in approach. Mhm. So we do have to wait for that feeling of feeling lighter and uh feeling a little bit um more energy on the inside. However, you are doing really well, okay, with um scheduling some new behaviors um to focus on that weren't there before. It also reminded me of something in the booklet perhaps that you could use. Remember when we looked at the booklet at the beginning and you highlighted key hadith that you were going to um remind yourself of? I wondered if um there was any that come to mind when we're looking at this. And I'm I'm saying perhaps be a little bit kinder to yourself um and and work on some of the um afternoon prayers rather than the difficult morning prayer at the moment. Is there anything that you want to remind yourself of? Um I think maybe this one. This is one of my favorite ones about the tire camel. So when we look at page eight here on the booklet um you know it's about when our prophet peace be upon him he noticed like a bedin who's going to leave his camel without tying it and he asked the bedin like why don't you tie the camel and the bed said well you know I put my trust in Allah and the prophet peace be upon him then said well tie your camel first then put your trust in Allah and that just got me going talking thinking about things that we've just spoken about here like you know it's an outside in approach and you know we need to do our yeah so that's really really good that you remembered that it's a really key one in this um behavioral activation technique that we're using which is the doing will bring difference in how you feel? Yeah. With time. Um, and when you mentioned earlier, I was going to comment on um it sounded like you were feeling upset from praying to Allah to get you up for the fud prayer, but not being able to meet that goal right now. Yeah. And then that might have made you feel worse from not achieving that goal. But this helise allows you to to perhaps focus on you're going to make some more um different action points and um behavioral goals for this week. If we could look at that and reminding yourself of this hadith, how you can pray to Allah, but also you're going to do your part in therapy where you're going to look at which which step do you want to start with. That's perhaps not the most difficult. if you had to grade the the prayers. You said the morning one's particularly difficult. Yeah. Which I thought it'd be the easiest because it's the shortest, but what I'm finding out is the most difficult one now. So feel Yeah. So, you know, um that bit at the beginning we talked about being merciful to yourself and that's what Islam teaches and being kind to yourself perhaps reminding yourself of that that you did give it a go and um that's true. you know, you know, I'm I'm really pleased that you did have a go at that and now we found that perhaps we want to change something. It's something um that we're going to perhaps give you another goal for next week and see how that goes. And sometimes it can feel like a bit um once you get some information on how you did, you can change your goal up. So, a bit like trial and error, but overall, you're still moving forward. you've incorporated that saw her prayer five times out of seven. Yeah. Which you should be really proud of. Yeah, that's true. In terms of what you've just seen, you know, again takes me back to that saying there that you do your part. I am doing my part, but I guess when I'm thinking that, you know, leave it to a lot. Yeah, that's fine. But I also need to physically do my part and it just got me thinking about what you've just said. So maybe you know like a thought pleasure might the the pleasure of prayer the first prayer might be the easiest but maybe it sounds like that might be the difficult one. Yeah. Yeah. So now we know that with your symptoms at this moment in time and they will change uh perhaps are you thinking about focusing on the the late afternoon prayer or the evening prayers? Which one would you like to swap it out with? I think maybe cuz I'm doing really well with the midday one, the afternoon one. So I want to keep that one going. So that's the second prize. I think the next one then might be let's try the midafter afternoon one as the next shortest towards the first one. Okay. Yeah. But the timing seemed like just before I get fatigue. So it's like late afternoon before having dinner and stuff. So maybe that might be quite helpful to do. So well done for identifying times of the day where it's less difficult for you to perhaps make a change and and and pray. And um well done for joining up that information that you know now know about yourself that the fatigue starts early evening. Yeah. You mentioned about sleep. I didn't I didn't think that well how exhausted you can feel when you feel depressed. Sure. So, it seemed like we're getting a bit of a plan together for next week's homework. I just wondered with one of the things that you'd said um earlier about wanting to pray all of your prayers and me like looking at that, it does feel really good that we were planning this, but I still don't feel like ah this is fine or this is okay. like it's not okay because as a Muslim we need to pray five times a day and I feel like I have to pray five times. So what we're doing in therapy is we're not um trying to say that you know it's okay to not pray five times. What we are doing is a stepby-step approach and you're climbing up to get to those five daily prayers. One thing that would be difficult is to overwhelm yourself with having all prayers reinccorporated. Um, how do you feel like you would cope with that if I if that was your behavioral goal for tomorrow? What as in read all five? Yeah. I think even the one that I'm reading, there's the the afternoon prayer would go because I'd just feel too exa exhausted. Yeah. Yeah. So knowing everything that you know um perhaps incorporating one and feeling some reinforcement from and some good uh feeling from achieving that will help you climb into the areas that are more difficult and the areas that perhaps you know like you've mentioned the fa prayer is more difficult. What will help you achieve that is getting the other prayers in place first. Perhaps that would make you feel that you're moving forward. Things are getting lighter like I mentioned um the outside in approach and things are becoming more automatic. So we'll we'll carry on with that. But I did want to highlight to you um one of the things in the booklet that you've um looked at before and you found quite helpful. Um and it was this just this hadith here. Do you remember this one that we looked at early on? Oh, yes. I forgot about this one. I'll just read it out to you and then we can see if it's something that you might want to um remind yourself of before you read your prayers or um perhaps you know write down and and reflect on when you're feeling low about not reading five times. So this um this reading here, this report from Abu Herrera is saying that the prophet peace be upon him said religion is easy and whoever overburdens himself with it will not be able to continue in that way. So you should try not to be extreme but try near perfection and accept the good tidings that you may be rewarded. gain strength by worshiping in the morning and during the last hours of the night but also underneath that the deeds which are most beloved to Allah are the ones that are done regularly even if little so what does that make you um how does that make you feel listening to that hadith that we've we mentioned it feels um especially what we just then what we just mentioned here like don't overburden yourself I feel like I was doing that and then the consistency is just kind of in a way giving me permission in in a way like it's okay to do it one step at a time cuz your intentions are there and we always spoke about intentions as well um how they matter. So yeah, it feels a bit enlightening actually to be reminded and even though I highlighted it, I again have forgot about all this. It really it was helpful actually to go through that and to kind of feel like yes, you're you're doing okay and that's Yeah. So well done. I mean this is quite a compassionate u reminder of how to to you know um to to work on the goals that we've set the two prayers and if we get them done regularly uh that's going to be pleasing to Allah. So perhaps you know that might be something to focus on rather than um what's been coming to mind is I'm not reading five times that makes you feel worse and and more stuck and then perhaps not able to make the changes that you want to make. Okay. Okay. So, how would you like to remember that, Hadith? Would you like to write it somewhere or take a picture of it or what would make it kind of something that would help you remember it and not forget? I think what I'm going to do here where I've pour it in into my activity diary, I'm just going to write a reminder here is to look at page and reread the hadith. That sounds like a good plan rather than writing it out. So then that's my reminder. Yeah. Excellent. So I think that's um that's as much as we need to cover for today. You've got a good plan there to focus on the two um prayers in the afternoon. You're going to remind yourself of the will help you achieve them and not feel overwhelmed. Um remind yourselves of the symptoms of depression that you have at the moment. sometimes makes it easier to avoid, but then long term, it sounds like you're saying you feel more more alone and and guilt feelings and and so on. So, in being merciful with yourself, I think you've created a a really good goal there, but how does that feel to you? Does it feel achievable? Feels a bit lighter in a way. And I think that will then let's see how it goes. But it feels doable and that's nice to know. Is there any difficulties that could arise that you can foresee at the moment to not get you to achieve the goals of the two afternoon pairs? Anything that you can at the moment? No, maybe the fatigue and stuff, but I think it's it's I won't know until I do it. Okay. It's one of those things. So, I think I'll be quite interested to bring back next session, see how we get on. Yeah. So well done for um setting yourself homework and I can see you next session and see how you've got on.

Session Demonstration — Transcript 2

[Production note: second transcript, showing a therapist and client working on an activation assignment involving the client's marriage, drawing on the Client Booklet.]

Well, thank you for coming back to your therapy session. Um, we looked at your values last time and um, you were identifying different areas of your life that have perhaps come away from where you wanted them to be um, and different areas of your life that you're finding difficulty in and where you want to make some changes. So if we start from there, I just wanted to perhaps look in on one of the values that we identified that's having some difficulty. It's um your relationship. Is that the relationship with your husband or Yeah, the relationship with my husband. Okay. So because of the symptoms of low mood, when someone's not feeling themselves, it can impact on lots of different areas of the life. and um your relationship with the husband. Do you want to tell me a little bit more how has that changed? Well, I lost my um father not long ago um and just since then um don't feel as close to my husband. Um can get quite snappy in a way um and I don't want to be because I know like our religion, you know, doesn't really shouldn't really be doing that with your spouse. You know, your spouse is supposed to be like the coolness of your eyes and stuff. So, um, yeah. So, I think it's just that breakdown like just fighting in a way, verbally, like not loud or anything, but just kind of always at each other's Yeah. sounds really difficult. Yeah. Okay. And um and is there a time where you feel like you were getting on better? Was it before um your father passed away? That must have been a really difficult time. Yeah, I think like um before that, yeah, we we we were like we were like best friends in that sense. We used to do lots of stuff together, especially with our children as well. Um stuff like you know bike riding just around the local park. Um every evening um after dinner we used to go for a walk, talk about our day um and none of that happens now. So those activities that you used to do together that you it sounds like you used to get some enjoyment from and some fulfillment from those aren't happening at the moment. No, not at all. And that's every that's been since you you lost your father and you've been going through that difficulty. Okay. So when we've looked at the booklet together in previous sessions, um one of the first pages looks at being merciful to yourself, being kinder to yourself. And one way that we can fit that in with changes that you're going to make through therapy and try out is perhaps we need to get you some more enjoyment and and fulfillment in some of the areas of your life. Um where you're finding that actually you're getting the opposite effect. you're getting some difficulty and you said you know it's been making you feel worse. So would that be a good area to focus in on this week looking at your marriage and how you can make a difference there? That'd be quite helpful actually. Yeah. Okay. So in doing that um there might be certain key areas of the booklet that can be used to motivate you to want to make a change from where things are. Um, and one of the things that you you highlighted when you first got this booklet was with hardship there is ease. Do you remember when you looked at that part? That's a passage from the Quran, isn't it? Yeah, it's one of my favorite passages actually. Uh, with hardship comes ease. So, thank you for highlighting that because as your therapist, I'm going to try and bring that into your therapy as much as possible as it's something that you you really find um helps you. So in what you've told me and the way things are, you might be going through some hardship right now. Um but let's see if you know we can make some changes and and and have have that hope of the ease going to come um through for through some um with some time. Okay. And then it was really apparent to me that you were doing some activities that together that you enjoyed and that's all stopped. And I wondered what would be what would be your thoughts on perhaps reintroducing one of those activities that you used to do that you've lost or stopped. It'd be nice to bring it back. Yeah. Can you think of anything that would get in the way of perhaps putting in a goal of maybe doing what would you like to choose? The bike riding, the walking you've mentioned. What would get in the way? I don't know if he he would want to do it anymore. Okay, that's a valid point. So, you don't know what his thoughts are about wanting to do it? Have you asked him about wanting to do it anytime recently since things have been hard? No. How do you how would you feel about asking him if you wanted to do choose one that you would perhaps find easier, the bike riding or the walking? Which one would it be? Or asking him which one? I think that sounds like a conversation that we do need to have. In terms of what might be easiest, I think the walk would be a bit more easier because it takes less energy. As we've spoken before in the other sessions, energy is not very good at the moment. It's the common symptom of low mood. So, I'm really glad that you've chosen the one that's easier that you used to do and now you're getting to um an area of thinking perhaps how can I make a change? The first thing first step as it mentions in the book that taking small steps um in a graded way is the way to kind of make a change. The first step would be to talk to your husband about would he like to start some walking up with you again. Then when I've asked you is there anything that would get in the way of that you've just mentioned you you're not sure if there's anything that would get in the way but you're also not sure of his response. So, would that prevent you from asking or do you think you could do you could perhaps ask him, schedule it? I think it's worth asking. Um, yeah, I think it's worth asking. Okay. So, with behavioral activation, one of the things that happens is we can have really good intentions to make a change. When it comes to it, we might just put it off as it's the easier option to take. It gives relief, provides relief. Um, but long term has its own negative consequences. is you might feel guilty or still stuck. Yeah. So, what I suggest is if you actually if you look at your week and you plan a time that you want to have that conversation, you're more likely to stick to it. It's more likely to happen. And the other thing that it will do for you is it'll allow you to see that that conversation's not going to last the whole day. Put a timing on it. So, maybe how long would feel doable to have a conversation about something like that. Yeah, that sounds quite good because I was just first thinking I'll do it later. But I guess what you just said here, if you just put a timing onto it and put it somewhere feels a bit less like even now like I'm fidgeting thinking I feel a bit anxious about this. Okay. Um but I guess if we put it somewhere, plan it in, put a timing on it, that just makes it a bit more better and easier in a way what you've just said is it'll get hopefully get done. Yeah. And how would you feel if you did have that conversation regardless of the um the outcome, the fact that you kind of met your goal, you're able to do it, you had it planned. How would you feel coming back and talking about that in therapy? Do you expect? I think I'd feel a bit good here. Um cuz it's something I'm avoiding as well, like to me short-term releases, isn't it? Not to think about it or do it. Yeah. So, I guess the fact that I did it doesn't even if he says like no, we're not doing it again or whatever. I guess I've done my part. Yeah. Excellent. That sounds like um something that we can plan in. Mhm. How we can schedule which is the best day, the best time for you. Um and like I was saying, finish that conversation within a certain time so you know it's not going to last the whole day. If you're feeling anxious about something, it's good to see the end time as well. So you'll have that conversation for what timing would feel realistic to have a conversation for? How long would it last? 10 minutes, 20 minutes, or think about 15. Okay. Yeah. Cuz just ask the conversation, but sometimes it's a whole buildup to it. Yeah. Okay. So I think no longer than 15 cuz I do ramble. So I don't want to ramble. Kind of want to get the point straight but then not seem like passive in a sense. Um, so yeah, that's I can see that. Um, you're really thinking about how it might go. Is there anything that would help you, a strategy that would help you to deal with the anxiety before the conversation happens? Anything from the booklet? Um, we've got the 99 names at the back there. Yeah, I was just thinking that as well, like um like a little prayer or something beforehand. Um, when I've been reading the booklet, there's no I, it's like I knew it, but I didn't know it that there's also meanings to each name here of we've got 99 names here of Allah and each name has a meaning. So maybe kind of like pick one or two and say that before I kind of in my head in my heart before I actually have that conversation with him just might make me feel a bit more calmer and lighter as well. Okay. So that's something you want to explore more. So, if you were to practice some of this um mindfully reading two names that you choose that resonate with you that makes you feel perhaps calmer and if you were to practice kind of saying that to yourself in a in a quiet moment before the day of having that conversation, it might be a tool that could help you to go into that conversation feeling a little bit calmer with those anxiety symptoms reduced. That's what I'm thinking as well. Yeah. Should we should we talk more about that next time when you come and see how it went? Yeah. Okay. Excellent. Thank you.