Dealing with thoughts in Behavioural Activation

Dealing with Thoughts in Behavioural Activation

“I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” — Client

Questions the therapist might ask:

• When did you start thinking that? What was happening then? How long did it last?
• What were you doing while you were thinking that?
• What else could you have done during that time?
• What is going on in your life that you are not enjoying/engaging with/or is passing you by whilst you are thinking in this way?

A Thought Record Sheet is provided at Appendix 7.

A client has expressed the need to feel better on the inside before they can change their behaviour. Discuss with the client that we often behave one way even though it may not correspond with how we feel on the inside. For example:

• We may feel hungry but… we would not eat food that may be in front of us that doesn’t belong to us.
• When we feel angry… we may restrain ourselves from shouting.

Therefore we are capable of behaving differently to how we feel internally.

Behavioural experts may sometimes describe BA as a form of CBT. Some forms of CBT emphasise cognition, while some emphasise behaviour, but in any form of CBT both cognition and behaviour are expected to change. In BA, the focus is on behaviour because this is often efficient and easy to do, but it is expected that cognition will change as well. In fact, there is evidence from an early study that BA is just as effective as cognitive therapy in changing negative thinking (Jacobson et al., 1996). This demonstrates that BA is not antagonistic to a CBT model.¹

1. Personal communication with Jonathon Kanter, University of Wisconsin–Milwaukee.

Companion Video Transcript

Behavioral theory treats thinking as behavior. The behavioral activation approach does not ignore the client's negative thoughts, but takes the position that we can activate behavior without having to change our thoughts first. Therefore, we are working from the outside in. The therapist would normalize the negative thoughts as being natural responses typical of someone who is depressed rather than challenging them but recognizing that they maintain the cycle of depression and feeling stuck.

Behavioral theory is that thinking is important but one does not need to challenge negative thinking in order to overcome depression. Therapists should focus on the context and consequences of thinking and treat thinking in the way that you would treat any other behavior. That is, focus on whether it is helpful in getting engaged with valued activities again rather than on the content or accuracy of the thoughts.

In behavioral activation, unhelpful thinking would be described as rumination behavior. When the client is ruminating about a particular thought, the therapist should not encourage the client to try to suppress, control, or change the thought, but aim to increase the client's awareness of when ruminating is occurring and whether the thinking is helpful or not. The next example demonstrates how to encourage alternative behavior that helps get the client out of his or her thoughts and…