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

1. Behavioral Activation Techniques for Depression in a variety of settings: Groups, Peer-to-Peer and Non-Clinical Settings by Susan L. Bandy, M.A., QMHP, LPC Chestnut Health Systems Granite City, Illinois

2. Order of Topics • Group Dynamics • Therapeutic Factors • Group Therapy Basics • Problem Severity • Behavioral Activation Techniques & Definition • Good Research Model

3. Order of Topics The Two Manuals: Original Form & Group Form Treatment Techniques & the Forms Assessments Uses of the Forms Overview of Tasks to be Accomplished Within the Group Session by Session Outline

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

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

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

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

8. Universal Group Dynamics Forming – cont *Scapegoating: “a process whereby anger and aggression are displaced onto another, usually less powerful group or persons not responsible for the aggressor’s frustration” (aka displacement or projection) Corsini, R. (Ed.). (2002). The dictionary of psychology (pp. 863). New York: Brunner-Routledge.

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

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

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

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

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

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

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

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

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

18. Universal Group Dynamics Norming/Performing - cont In the beginning the group will exhibit much pride in their unity and possibly much condemnation of the member’s adversaries outside the group. Eventually this glow will pale and the group must be allowed to express difficulties, conflicts and differentiation – otherwise the group will fail.

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

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

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

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

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

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

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

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

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

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

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

30. Group Therapy:Therapeutic Factors Gaining Insight Insight occurs when one discovers something important about oneself – about one’s behavior, one’s motivation, or one’s unconscious. Results: individual realizes they have the power to change their behavior.

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

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

33. Group Therapy:Therapeutic Factors Existential Factors Recognizing that life is at times unfair and unjust. Recognizing that ultimately there is no escape from some of life’s pain and from death. Recognizing that no matter how close we get to other people, we must still face life alone.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

50. Treatment Techniques & The Forms Orientation to therapy Instillation of hope & explanation of how therapy works Daily Activity Record Establish pattern of activity for previous 7 days Functional Assessment Establish baseline Life Activities Checklist Life Areas Assessment Behavior Contract Activity Hierarchy