Brief Counseling Techniques for Your
Most Challenging Patients
Behavioral Activation Treatment:
Planning then Acting to Improve Quality
of Life
Avi Kriechman, M.D.
UNM Department of Psychiatry
Center for Rural and Community Behavioral Health
Division of Child and Adolescent Psychiatry
Objectives
• Describe the rationale for behavioral activation
• Identify activities to help patients reconnect with
their values across several life areas
Objectives (cont.)
• Use activity structuring and scheduling with
patients to better engage in adaptive activities they
associate with pleasure and/or mastery
• Identify ways to help patient’s discover their
barriers to engaging in adaptive activities in order
to maintain and increase them
Overview of Behavioral Activation
• Help patients reconnect with their values by
examining how they are currently living according
to these values
• Help patients identify activities that fit their values
• Help patient utilize structure and planning to live
a valued life on a daily basis.
Behavioral Activation:
Guiding Principles for the Provider
Structure and schedule activities that follow a plan,
not a mood
Emphasize activities that are naturally reinforcing
Emphasize a problem-solving approach where all
results are useful
Role of provider as coach
Emphasize the motto “Don’t just talk, do!”
Troubleshoot possible and actual barriers to
activation
Process of Behavioral Activation
• Begin with rationale for behavioral activation
• Identify life areas, values, and activities
• Contract behaviors to increase social support
• Emphasize behavioral assessment through daily
activity and mood monitoring to determine targets
for intervention
Rationale for Behavioral Activation
The less you do the more depressed you feel
The more depressed you feel the less you do
The Cycle of Fear and Avoidance
Identify Life Areas
Life Areas
Identify Values
Values are how you want to live your life
They are more general statements about
what’s really important to you
Values should be determined for all life
areas
Life Areas & Values Lead to Activities
Contract Behaviors to
Increase Social Support
Recruit social support
Behavior Monitoring
Monitor current patterns of behavior
Rate Importance / Enjoyment / Mastery
Identify which activities patient might
want to increase/decrease
Daily Monitoring
Behavioral Activation involves
Pleasant Activities
Increase activities associated with pleasure
Re-introduce prior pleasant activities: Can you
think of any activities or hobbies you used to enjoy
but have now stopping doing?
Introduce new pleasant activities: Can you think
of any activities or hobbies you would like to do
but have never done?
Types of Pleasant Activities
Pleasant activities are ones that make you
feel better because they are rewarding,
meaningful, inspiring, relaxing or fun.
They don’t have to be special activities. In
fact, most are everyday activities.
Remembering Pleasant Activities
When a person is depressed, it’s hard for
them to remember any activities have ever
been pleasant.
Ask them what it is that they used to enjoy,
no matter how long ago.
Go Slow
• Use activity structuring and scheduling to increase
adaptive activities
• Consider difficulty of tasks and efforts needed to
do them, then start slow to allow for early success
Pleasant Activities Are the Best First Step
Pleasant activities are doubly beneficial to the patient
as they increase activity and feelings of pleasure.
Activities designed to overcome avoidance or increase a
sense of accomplishment should be entertained as the
first goals only if highly important to the patient or
apparently salient to the attainment of future goals
Behavioral Activation involves Active Coping
Active coping = taking some form of
behavioral action to alleviate or reduce
a life stressor.
The goal of active coping is to decrease
stress through accomplishment or
overcoming avoidance.
Behavioral Activation involves
Active Coping (cont.)
Ask if there is something the patient needs to do
that she/he has been unable to do or has been
avoiding.
Some patients may want to accomplish something
rather than focus on doing something pleasant.
(Examples: calling an estranged family member,
cleaning out a messy closet, getting taxes done).
Behavioral Activation for Avoidance
Where the activity itself is not reinforcing
(pleasant) but feared.
It is only in the completion of the task that
the patient feels good (I faced my fear and
nothing terrible happened)
Behavioral Activation for Avoidance
(cont.)
To effectively apply behavioral activation
with anxious patients, it is important to
monitor anxiety and combine behavioral
activation with relaxation techniques to
increase patient comfort and control.
Barriers
• Identify barriers to activation
• When barriers to activity arise, asses the
function of the behavior and generate
solutions for future activation assignments
• Use problem solving to alter contextual
problems that may be eliciting or
maintaining undesired behaviors
Behavioral Activation for Avoidance
Be careful not to allow behavioral
activation to further aid in the patient’s
avoidance of fearful situations (playing
video games solo rather than engaging
with family)
Setting a Plan into Action
Identify specific, observable, measurable tasks
Tasks are within the context of values and/or goals
important to the patient
Set realistic behavior requirements
Break big tasks down into more simple ones
Setting a Plan into Action
Role play / rehearse task in the office
Use visualization / imagery
Assign “homework” that is engaging and satisfying
Set timeframe for monitoring progress
Setting a Plan into Action
Identify possible facilitators of obtaining the goal
(important people or situations that might aid the
patient). Look for ways others can help
Understand patient’s confidence in reaching the goal
in the timeline established. If confidence is low, alter
the plan to increase chances of success.
Teach skills patient might want to enlist to help reach
goal (relation skills, problem solving skills, etc.)
Example of a Simple Action Plan
Goal: Exercise on a recumbent bike a minimum of 20
minutes per session at least three times a week
Timeframe: Patient will complete three bike-riding
sessions over the next week
Homework Assignments
What activities did you previously enjoy that you
would like to start participating in again?
List activities that you need to do to better your current
situation (enroll in school, get your inspection sticker,
etc.)
Create a schedule of the new activities you will
perform. Which ones did you accomplish? Were there
any barriers? Why? How did you handle them?
Monitor Progress
in Enjoyment and Mastery
Don’t forget to…
• Consolidate treatment gains
• Plan for relapse prevention
Selected References
Behavioral Activation for Depression: A Clinician’s Guide by
Martell, Dimidjian, Herman-Dunn & Lewinsohn
The Origins and Current Status of Behavioral Activation
Treatments for Depression by Dimidjian, Barrera, Martell,
Munoz & Lewinsohn
Behavioral Activation and Inhibition Systems and the
Severity and Course of Depression by Kasch, Rottenberg,
Arnow & Gotlib
