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De-Press = Press down - Association for Contextual Behavioral
What is Depression? MDD – Melancholic Behavioral Activation and ACT Mixed Anxiety–Depressive Disorder MDD – Atypical Recurrent Brief Depressive Disorder Jonathan W. Kanter, Ph.D. University of Wisconsin-Milwaukee Milwaukee, Wisconsin, USA jkanter@uwm.edu Minor Depressive Disorder Dysthymic Disorder Premenstrual Dysphoric Disorder Depressive PD 4 1 Identify three activities to schedule today What is Depression? Core experience: Depressed mood and behavior Values Assessment: What do you value? Activity Monitoring: What are you already doing? Informal clinical interview: What have you stopped doing? Pleasant Events Schedule: What might you enjoy doing? De-Press = Press down 2 5 Value Examples Relations with family Want to be a good daughter/son/sibling: Call family at least once, buy souvenirs Relations with spouse Want to be considerate of my partner while I’m away: Text or intimate partner often. Relations with friends Rekindle friendships with colleagues: Ask out to lunch even though haven’t talked to them in 2 years. Religion and Want to keep up with spiritual routine: Attend a service nearby, spirituality take time to meditate Meaningful work (paid Stay current on ______ area: Attend lectures even if no CEUs or not paid) offered because they are interesting. Cultural roots Speak Spanish with others if there is an opportunity Recreation, hobbies, Learn about the arts: Take an afternoon off to visit the local creative expression museums. Volunteer activity Environmentalism is important to me: Encourage recycling of (community, church) fellow conference attendees Physical well being, Keep up with running schedule: Wake up early enough to run health before Life organization and Want to attend as much as possible, as cheaply as possible: time management Make a schedule, budget – only 1 book! Finances Do not overspend on drinks in evening; stay in budget What is Depression? BA Context Mood Reinforcement Negative Life Events ↓ R+ for healthy behavior (↑R- and R+ for depressed behavior) ↑ depressed mood Behavior ↓ activation (↑avoidance and depressed behavior) Manos, R. C., Kanter, J. W., & Busch, A. M. (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology Review. 1 What is Depression? Language Mood Reinforcement “Control agenda” ↓ R+ for healthy behavior Fusion Context of literality ACT (↑R- and R+ for depressed behavior) Activity Scheduling, Social Skills Training: Lewinsohn 1980s Cognitive Therapy: Beck Coping with Depression: Lewinsohn ↑ depressed mood 1990s Behavior ↓ activation (↑avoidance and depressed behavior) Manos, R. C., Kanter, J. W., & Busch, A. M. (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology Component Analysis: Jacobson BATD: Lejuez 2000s 2010s BA: Martell Alternatives, Adaptations, Elaborations Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation? A review of the empirical literature. Clinical Psychology Review. 10 Review. What is Depression? Language ↓ R+ for healthy behavior (↑R- and R+ for depressed behavior) Behavioral Activation ACT Mood Reinforcement Relational transformation of stimulus functions History of BA 1970s ↑ depressed mood Behavior ↓ activation (↑avoidance and depressed behavior) META-ANALYSES? MEDICATION? BA vs. control = .87 (N = 10): Cuijpers et al. (2007) As effective as meds for more severe depression BA vs. CT = .01 (N = 15): Mazzucchelli et Lower drop out rates “EMPIRICALLY SUPPORTED?” RECENT /CURRENT RESEARCH? “Efficacious” empirically supported treatment: DeRubeis & PTSD *Inpatient depression Cancer patients Obesity Comp. bereavement *Depressed smokers Homebound smokers Medical adherence Homosexual meth users *Inner city drug users Bipolar depression Dementia caregivers Geriatric depression Adolescents *College students Crits-Christoph (1998) al. (2010) BA vs. CT (2 yr) = .00 (N = 2): Mazzucchelli et al. (2010) Better survival than discontinued meds Dimidjian et al. (2006) “Well established” empirically validated treatment: Mazzucchelli et al. (2010) Manos, R. C., Kanter, J. W., & Busch, A. M. (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology 11 Review. What is Depression? 2. Verbal, derived relational contingencies What is BA? Lewinsohn’s early approach Others 1. Direct, environmental contingencies Gallagher (Elderly) ↓ R+ Manos, R. C., Kanter, J. W., & Busch, A. M. (2010). A critical review of assessment strategies to measure the behavioral activation model of depression. Clinical Psychology Rehm (Selfcontrol) Beck’s CT BA (Martell) BATD (Lejuez) Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation? A review of the empirical literature. Clinical Psychology Review. 12 2 What is BA? BA and ACT? Core Component: Activity Scheduling Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation? A review of the empirical literature. Clinical Psychology Review. Use BA as a simple frontline treatment that sets up creative hopelessness if it fails. 13 14 What is BA? Valuing Self as Context 16 Creative hopelessness Committed Action Valuing Defusion and Acceptance Self as Context Kanter, J. W., Baruch, D. E., & Gaynor, S. T. (2006). Acceptance and commitment therapy and behavioral activation for the treatment of depression: Description and comparison. The Behavior Analyst, 29, 161-185. 17 Today’s Goal Entirely consistent with ACT Easier to implement than ACT Easier for clients to understand than ACT As front line treatment: Kanter, J. W., Baruch, D. E., & Gaynor, S. T. (2006). Acceptance and commitment therapy and behavioral activation for the treatment of depression: Description and comparison. The Behavior Analyst, 29, 161-185. Defusion and Acceptance Kanter, J. W., Baruch, D. E., & Gaynor, S. T. (2006). Acceptance and commitment therapy and behavioral activation for the treatment of depression: Description and comparison. The Behavior Analyst, 29, 161-185. Use BA strategies to maximize the effectiveness of committed action work in ACT. Activity scheduling to facilitate contact with diverse and stable sources of positive reinforcement Committed Action BA and ACT? Goal of therapy: The meaning of life: Creative hopelessness 15 Providing BA’s rationale Determining activities to schedule (values) (activity monitoring) Scheduling activities Additional strategies = ACT 18 3 Create a Hierarchy Today’s Goal Informal interview: What has the client stopped doing? During committed action: Providing BA’s rationale Determining activities to schedule (values) (activity monitoring) Scheduling activities Additional strategies Values Assessment: What does the client value? Activity Monitoring: What is the client currently doing? Other goals 19 22 EXAMPLE: TK Five Tips for Good Activity Scheduling 1. Routine/Lifestyle: • • 1.Guide assignments with the case conceptualization (Activity Hierarchy) 2.Grade assignments by task difficulty (shaping) 3.Break assignments into manageable chunks (chaining) 4.Make assignments concrete and specific 5.Problem-solve obstacles to completion • Gym and stretching Sleep hygiene: Caffeine, wake up times, nighttime wake up routines Food: Apples, milk, portion sizes 2. Fun/enjoyable activities • Bike rides, museums, visit family, air show, playing video games 3. Social activity • • Social opportunities at work: Guards, superiors, supervisees Same-age social opportunities: Church, classes, volunteering (no set ups, no online dating) 4. Employment 20 23 Tip # 2: Grade assignments by task difficulty (shaping) Tip # 1: Assign activities based on your case conceptualization Assign the least difficult activities first to foster early success Activity Hierarchy should represent: • Stable, meaningful reinforcers • Diverse activities • Range of difficulty levels • Valued activities • Routine activities • Fun, enjoyable activities Plant new vegetables Photography Fix old bike Anticipated Difficulty Assigned Completed Actual Difficulty 7 3 7 Help child with homework Play ball on weekend 3 1 5/17/10 no 7 Walk dog when want to nap Go for walk at 4 in afternoon 4 5/24/10 II III Look for jobs online Look through want ads Study for GED 2 5/17/10 II 4 5/31/10 5/32/10 Anticipated Difficulty Assigned Completed Actual Difficulty 7 3 7 Help child with homework Play ball on weekend 3 1 5/17/10 no 7 2 Walk dog when want to nap Go for walk at 4 in afternoon 4 5/24/10 II III 2 1 Look for jobs online Look through want ads Study for GED 2 5/17/10 II 1 4 5/31/10 8 6 Activity Plant new vegetables Photography Fix old bike 8 6 4 Tip # 2: Grade assignments by task difficulty (shaping) Tip # 5: Consider and problem-solve obstacles to completion Activity Is this task challenging enough so that you will feel a sense of accomplishment if you do it? Is it too challenging? Will you feel overwhelmed? Let’s find a task that is just right—challenging enough for you to complete and feel good about, but not so challenging that you won’t do it. Anticipated Difficulty Plant new vegetables Photography Fix old bike Assigned Completed Actual Difficulty 1. Find basketball shoes 2. Call friend and ask for other friend’s phone numbers. 3. Call friends to ask about playing and ask for a ride Consider and assign intermediate steps 7 3 1 5/17/10 no 7 Walk dog when want to nap Go for walk at 4 in afternoon 4 5/24/10 II III 2 Look for jobs online Look through want ads Study for GED 2 5/17/10 II 1 4 5/31/10 Call friend during week to play ball on weekend Call Jaden, ask about playing and getting a ride, from home Thursday evening after dinner Outcome “What obstacles may get in the way of completing this activity?” “Take your time and think about it for a minute.” 6 Tip # 5: Consider and problem-solve obstacles to completion Activity Anticipated Difficulty Plant new vegetables Photography Fix old bike Assigned Completed Actual Difficulty Activity w/w/w/w Call friend during week to play ball on weekend Call Jaden, ask about playing and getting a ride, from home Thursday evening after dinner 7 3 7 Obstacles Feeling unmotivated Look for jobs online Help child with homework Play ball on weekend 3 1 5/17/10 no 7 Walk dog when want to nap Go for walk at 4 in afternoon 4 5/24/10 II III 2 Look for jobs online Look through want ads Study for GED 2 5/17/10 II 1 4 5/31/10 Solutions to obstacles Outcome Turn on ESPN on tv to remind self how much It Iis like playing often useful to consider “feeling” obstacles that may disrupt activities. Here is where you may start to build an ACT conceptualization if BA does not succeed: 8 Look for ACT obstacles to activation. 6 Tip # 5: Consider and problem-solve obstacles to completion Who do you need to talk to accomplishOutcome this goal? Obstacles Feeling unmotivated Solutions to obstacles 8 Who w/w/w/w Obstacles Feeling unmotivated Look for jobs online Help child with homework Play ball on weekend Tip # 4: Make assignments concrete and specific Activity w/w/w/w Call Jaden, ask about playing and getting a ride, from home Thursday evening after dinner 3 7 Tip # 3: Break assignments into manageable chunks (chaining) Playing basketball on weekend: Activity Call friend during week to play ball on weekend Solutions to obstacles Prepare a few time and place suggestions What Look for jobs online Where When Who might be able to support you in this task? What do you need to do specifically to accomplish the task? Where will this activity take place? Activity w/w/w/w Call friend during week to play ball on weekend Problem Call Jaden, ask about playing and getting a ride, from solve obstacles home Thursday evening after dinner Develop back-up plans Obstacles Solutions to obstacles Outcome Feeling unmotivated Turn on ESPN on tv to remind self how much I Jaden might like playing not be home Call again Friday Look for jobs online Do you have transportation figured out? When do you plan on working on this task? Do you have a deadline to meet? 5 Obstacles Feeling unmotivated Jaden might not be home Solutions to obstacles Outcome Turn on ESPN on tv to remind self how much I like playing Partially completed - called Saturday morning Call again Friday Did you remember at the right time and place? Did you have it written on your activity monitoring or planner, etc? Look for jobs online Did you try to use any reminders – written or from friends? Do you think this would have helped? Did completing the assignment require you to say no to or ask others for permission? Did you have trouble figuring out how to get these people to listen to you? Did you know what to say and how to say it effectively? NON-SOCIAL SKILLS w/w/w/w Call Jaden, ask about playing and getting a ride, from home Thursday evening after dinner PROBLEM SOLVING Activity Call friend during week to play ball on weekend Did you remember to do the assignment? SOCIAL SKILLS Functional Assessment Procedure Workshop Activation Sheet Did you know how to do the assignment effectively? Have you done it before? Do you feel that there are other skills, experiences, etc. that you might need to do this well? Was the problem fitting this assignment into an packed schedule? Was there just not enough time in the day? Did other unforeseen obstacles interfere? Did you have trouble coming up with solutions to these obstacles? Did others distract you from starting or completing the assignment? How did others react? Did others do the assignment for you? Did you spend a lot of time thinking about the assignment but not doing anything? Imagine you are starting the assignment, what do you feel? How does thinking about the doing the assignment make you feel? Is this assignment just really boring and you’d rather not do it? Did you just avoid doing it? Is this assignment just a chore? Something you don’t really care about but just have to do? Were you just too tired, fatigued or lacking energy to start the assignment? Did you get sidetracked by more enjoyable or easier activities, like watching tv? Did you feel this assignment was beneath you or childish? Did you feel you couldn’t do the assignment alone? Did you get anything positive from not doing the assignment?? Were you hopeless about doing the assignment, or hopeless that doing it would help? ANTECEDENT FAILURE: BEHAVIOR FAILURE: CONSEQUENCES FAILURE: CONSEQUENCES FAILURE: Forgetting Skills Deficit Public Private Stimulus Control Activity Scheduling Skills Training Contingency Management Strategies Targeting Avoidance FUNCTIONAL ASSESSMENT PROCEDURE Did the therapist… 1 Identify appropriate level of assignment difficulty (Tip 2) 2 Break assignment into appropriate chunks (Tip 3) 3 Make assignment concrete and specific (Tip 4) 4 Discuss obstacles to assignment completion (Tip 5) 5 Problem solve obstacles to assignment completion (Tip 5) ANTECEDENT FAILURE: BEHAVIOR FAILURE: CONSEQUENCES FAILURE: CONSEQUENCES FAILURE: Forgetting Skills Deficit Public Private Stimulus Control Skills Training Contingency Management Strategies Targeting Avoidance Reminders, prompts Social skills Contract with self See slides Tell someone Non-social skills Contracts with others Problem solving skills Additional strategies when activity scheduling does not succeed FUNCTIONAL ASSESSMENT PROCEDURE ANTECEDENT FAILURE: BEHAVIOR FAILURE: CONSEQUENCES FAILURE: CONSEQUENCES FAILURE: Forgetting Skills Deficit Public Private Skills Training Contingency Management Dealing with thoughts and emotions in BA Stimulus Control Strategies Targeting Avoidance Normalize that negative thoughts and emotions are inevitable. Important to activate with negative thoughts and emotions. Working from the “Outside-In” requires accepting what is “In” 36 6 “TWO CIRCLES” MODEL OF BA “I was depressed all day yesterday because I was thinking about how my sister really doesn’t love me.” 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? Trauma, violence Unemployment, homelessness Physical/medical conditions Accumulation of daily stressors Disruptive “positive” events Pregnancy, childbirth Poor social support, marital dissatisfaction Divorce, widowhood, death of loved ones Separation from family Negative life events 37 40 Dealing with Rumination in BA “TWO CIRCLES” MODEL OF BA Increase awareness of when ruminating is occurring Don’t try to suppress, control or change the thoughts Assess if the thinking is helpful or not Activate alternative behavior that gets client out of mind and into experience Natural Response Sadness, feeling down, feeling blue, crying more, feeling depressed, anhedonia, grief reactions, fear, despair, hopelessness Staying in bed, sleeping too much, withdrawing from friends/family, stopping housework, stopping looking for work, drinking too much, smoking, using drugs, overusing prescription meds, filling everyNegative minute of the day to avoid facing problems, watching tv, lashing out at life events others, trying to kill yourself, acting like life is already over 38 “TWO CIRCLES” MODEL OF BA BA Strategies for Avoidance 1 2 Did the therapist… Help the client distinguish between specific emotional responses and avoidance responses while validating the responses (e.g., 3 circles model)? Discuss the positive short-term but negative long-term consequences of avoidance (e.g., using 3 circles model)? 3 Remind client of BA’s “outside-in” approach to behavior in the presence of aversive emotional responses (e.g., fireman metaphor)? 4 Re-visit Tip 2 (grade the assignment) and Tip 3 (break into chunks) in light of client’s aversive response? 5 Link activity completion to the client’s values? 6 41 Natural Response “The important point I want to make is that these responses make sense, they are perfectly natural. You are not weak or crazy for having them. You are normal. But what has happened to your life since you starting reacting this way?” Negative life events Direct client’s attention to immediate experience if ruminating? 39 42 7 “TWO CIRCLES” MODEL OF BA 3 Circles Model 2 Did the therapist… Elicit from the client and list appropriate negative life events? (have client tell his/her story) Elicit from the client and list natural responses? 3 Validate natural responses by linking them to negative life events? 4 6 Demonstrate spiral by linking natural responses to more negative life events? Discuss goal of treatment is to break cycle with activation as alternatives to natural responses? Responds to “just do it” challenge: Behavioral expertise is needed 7 Responds to “inside-out” challenge: Active vs. passive approach is needed 8 Responds to “broken brain” challenge: BA changes the brain 10 Obtain feedback on the model? 1 Responses Avoidance Patterns (Natural, common) (Natural, common) sadness feeling down feeling blue crying more feeling depressed less pleasure grief fear despair 43 hopelessness… Triggers (Negative Life Events) staying in bed sleeping too much social withdrawal calling in sick stopping job search drinking too much using drugs watching tv lashing out trying to kill self… “TWO CIRCLES” MODEL OF BA 5 46 Open Discussion and Questions Activation “To summarize, when negative events happen, people shut down. So this treatment is about getting you active again. Our goal will be to develop action plans and goals for you, and then help you act according to these plans or goals rather than according to your feelings. Our goal will be to first identify how you have shut down, what you have stopped doing, what you are actively avoiding, what gives you a sense of pleasure, what gives you a sense of accomplishment, and what you really, truly care about. jkanter@uwm.edu Negative life events 44 “TWO CIRCLES” MODEL OF BA Activation “Then, our goal will be to activate you to reengage in life, experience more pleasure and accomplishment, start doing what you have stopped, approach the things you are avoiding, solve major life problems, and act consistently with what you really care about.” Improved life 45 8
