1. Christopher R. Martell, Ph.D., ABPP & Derek R. Hopko, Ph.D.
PPiPCare
Psychological Perspectives in Primary Care Using Behavioural Activation Techniques in Primary Care
Christopher R. Martell, Ph.D., ABPP & Derek R. Hopko, Ph.D.

2. An overview of PPiPCare
6 modules, accredited by the RCGP, chosen by GPs and written by leading experts in the relevant field.
Designed to be portable (i.e., can be run anywhere, at anytime) and flexible (i.e., can be customised to local need, and amount of time available).
Includes relevant evidence-based techniques, as well as guidance on how these techniques can be integrated within routine clinical practice within the primary care setting.

3. PPiPCare Modules
Using behavioural activation techniques in primary care
Using motivational interviewing techniques in primary care
Using problem solving techniques in primary care
Using guided self-help techniques in primary care
Detecting anxiety and depression in primary care
Detecting anxiety and depression in primary care: working with older people

4. PPiPCare Modules
Using behavioural activation techniques in primary care
Using motivational interviewing techniques in primary care
Using problem solving techniques in primary care
Using guided self-help techniques in primary care
Detecting anxiety and depression in primary care
Detecting anxiety and depression in primary care: working with older people

5. Overview of this module: Behavioural Activation
Aim
To develop knowledge and understanding of Behavioural Activation (BA) and its use in primary care
Learning Outcomes – by the end of this module the learner should know:
What Behavioural Activation is and how it targets depressive symptoms
What Behavioural Activation may offer over and above anti-depressant medication
How to use Behavioural Activation in primary care

6. Full BA versus BA techniques
A word of caution: Full BA training takes a quite a while and we don’t have that.
Need to say something here about not doing BA ‘proper’, what we are going to be doing is drawing on some of the principles and techniques that are involved , and thinking about how we can adapt them for use in primary care with the associated restraints in time etc etc

7. Why not stick with anti-depressants?
BA is as effective as antidepressants for mild to moderate depression and is considered an ‘empirically validated treatment’ (Mazzucchelli et al., 2009; Sturmey, 2009). See p. 2 of handout.
Depression is a chronic condition, normally with a number of episodes over the course of one’s lifetime. BA is better than anti-depressant medication in the long-term, and at preventing future episodes (Dobson et al., 2008).

8. Why not stick with anti-depressants?
Has been adapted for use within ethnic minority groups e.g. Mir et al (2015) adapted for use with Muslim population
This article is included in the articles folder:
Background
Incorporating religious beliefs into mental health therapy is associated with positive treatment outcomes. However, evidence about faith-sensitive therapies for minority religious groups is limited.
Methods
Behavioural Activation (BA), an effective psychological therapy for depressionemphasising client values, was adapted for Muslim patients using a robust process that retained core effective elements of BA. The adapted intervention built on evidence synthesised from a systematic review of the literature, qualitative interviews with 29 key informants and findings from a feasibility study involving 19 patients and 13 mental health practitioners.
Results
Core elements of the BA model were acceptable to Muslim patients. Religious teachings could potentially reinforce and enhance BA strategies and concepts were more familiar to patients and more valued than the standard approaches. Patients appreciated therapist professionalism and empathy more than shared religious identity but did expect therapist acceptance that Islamic teachings could be helpful. Patients were generally enthusiastic about the approach, which proved acceptable and feasible to most participants; however, therapists needed more support than anticipated to implement the intervention.
Limitations
The study did not re-explore effectiveness of the intervention within this specific population. Strategies to address implementation issues highlighted require further research.

9. The depression cycle: the jargon-free version
Life events
Circumstances

10. The depression cycle: the jargon-free version
Life events
Circumstances
Depression

11. The depression cycle: the jargon-free version
Life events
Circumstances
↑ avoidance
↓ energy
Withdrawal and non-engagement
Depression

12. The depression cycle: the jargon-free version
Life events
Circumstances
↑ avoidance
↓ energy
Withdrawal and non-engagement
Depression
Lack of positive reinforcement from everyday activities:
↓ self-esteem
↓ energy
↓ sense of being able to cope

13. The depression cycle: the jargon-free version
Life events
Circumstances
↑ avoidance
↓ energy
Withdrawal and non-engagement
Depression
Lack of positive reinforcement from everyday activities:
↓ self-esteem
↓ energy
↓ sense of being able to cope

14. The depression cycle: the jargon-free version
Life events
Circumstances
↑ avoidance
↓ energy
Withdrawal and non-engagement
Depression
Lack of positive reinforcement from everyday activities:
↓ self-esteem
↓ energy
↓ sense of being able to cope

15. The depression cycle: the jargon-free version
Life events
Circumstances
↑ avoidance
↓ energy
Withdrawal and non-engagement
Depression
Lack of positive reinforcement from everyday activities:
↓ self-esteem
↓ energy
↓ sense of being able to cope
Ask if this relates to your patients
Many of the behaviours such as staying in bed, being late for work, or not going to work, make sense when considering the way the individual feels.
The problem is that as one avoids, broods, de-activates, the depressive symptoms get worse not better.
Life is less rewarding when you are depressed

16. To put it simply...
BA is about breaking the negative vicious cycle whereby depressed individuals do less because they feel depressed, and feel more depressed because they are doing less.
It’s about introducing relevant pleasant activity into the day in order to foster a sense of enjoyment, pleasure and achievement.

17. How do we deliver BA techniques in primary care?
Please remember – we are talking about using some BA techniques – not full BA.
Ideal – longer session, weekly reviews, working through material together
Clinical reality- brief contact, review appointment more greatly spaced, limited time to work through materials. Possibly ten minute sessions over 2-3 months, or whatever is workable in your clinical practice.

18. A case example: Simon
Simon, 29 has come to see you for a review of his anti-depressant medication. He has been depressed for about a year and no longer feels that this medication is effective. He lost his job about six months ago and has been unable to find work since. His mood is very low, and his self-esteem is also poor, which he acknowledges has been worse since being unemployed. He is currently living with his long-term girlfriend, but this relationship is difficult, in large part because of his depression. He is fairly hopeless about the future, and finds it difficult to be motivated, spending a large part of the day either in bed, or watching the television.

19. Your role in BA Initially engaging Simon to this approach
Supporting Simon in this process
Reviewing progress and problem solving

20. Your role in BA Initially engaging Simon to this approach
Supporting Simon in this process
Reviewing progress and problem solving

21. Engaging the patient
Listen to his concerns, validate, normalise and provide psychoeducation.
I don’t think I can do it....I can’t even get out of bed some days...
I don’t want to do this – can’t I just try a different anti-depressant?
If I try and I don’t manage it, I think it might make me feel even more useless than I do already....

22. A case conceptualisation
Life events
Circumstances
How do you behave when you feel depressed? What happens?
Depression
How do these changes in behaviour make you feel? What happens?

23. Engaging the patient
Providing a rationale for this approach and hope for change:
Think about their circumstances. Make the depression cycle personal to them to illustrate how their depression may be maintained (the vicious cycle), and how this approach can break that cycle.
Reassure the patient that these techniques are effective and have been shown to work for other individuals in similar circumstances.
Listen to individual concerns and talk through these with the patient.

24. Your role in BA Initially engaging Simon to this approach
Supporting Simon in this process
Reviewing progress and problem solving

25. Supporting the patient
Get a baseline measure of activity with an activity diary, and get patient to rate enjoyment of each activity.
Identification of areas of potential reward for patient and help in choosing which to engage in (hierarchy of difficulty).
Maximising likelihood of success (think about barriers, break into smaller steps etc).

26. Weekly Activity Schedule
NOTE: Grade activities A for Sense of Achievement P for Pleasure C for Connectivity
(0 = no sense of achievement, pleasure or connectivity to 10 = extreme sense of achievement, pleasure and connectivity)
MON
TUES
WED
THURS
FRI
SAT
SUN
8-9
9-10
10-11
11-12
12-1
1-2
2-3
3-4
4-5
5-6
6-7
7-8
8-12

27. Supporting the patient
Activity Scheduling
(see p of handout)
Plan in advance for a day and time to complete the task
Anticipate difficulties
Keep scheduling until the patient does the activity on a regular basis.

28. Supporting the patient
Activity Monitoring
(see p of handout)
Request that the patient indicate how “MOST” of each hour was spent in terms of a primary behavior (e.g., sleeping, eating, watching television).

29. Supporting the patient
Elicit specific goals from the patient
(see p. 6-7 of handout)

30. Supporting the patient
What goals might Simon have, and what might be some associated target behaviours?
DEVELOP BETTER RELATIONSHIP WITH MY PARTNER
A. Cook Dinner
B. Baby sit son so she can spend time with friends
C. Go out on a date
D. Tell partner I love her
E. Ask partner how I can better meet her needs
IMPROVE MY HEALTH
A. Go to sleep before midnight
B. Exercise (walk 30 min/4 days per week)
C. Eat home-cooked meals
D. Take Multi-Vitamin
E. Increase water intake
F. Chew gum rather than smoke after dinner

31. Supporting the patient
Maximising likelihood of success:
Create a hierarchy - order activities based on perceived difficulty. Start with the easier items and work through.
Break things down – change is easier when tasks are broken down into smaller components. The task doesn’t have to be completed all in one go.

32. Your role in BA To recap:
What could you do to support Simon with Behavioural Activation?
Psychoeducation
Formulation
Activity Scheduling/Monitoring
Goal Setting

33. Your role in BA Initially engaging Simon to this approach
Supporting Simon in this process
Reviewing progress and problem solving

34. Reviewing progress and problem solving
Monitor level of depression with a standardised assessment tool e.g. PHQ-9
How does the patient feel about it?
What is going well and not so well?

35. Reviewing progress and problem solving
Remember:
Patients must repeatedly engage in pleasurable activities in order for them to have an anti-depressant effect – otherwise you are not giving activation a fair chance.
This is not a naïve approach. Nobody expects that patients will feel better because they did a few simple tasks like walk around the block, or wash the dishes, but they have to start somewhere, and start small.

36. Reviewing progress and problem solving
Remember:
As patients begin to activate, they may run into problems.
It is helpful to help patients identify avoidance behaviors and choose to engage/activate, rather than avoid.
Rule of thumb: “if it feels good in the short-run, but causes more problems in the long-run, it may be avoidance.” Look at the consequences of avoidance.

37. What does BA look like in Primary Care?
Use the time to achieve key aims: Explain rationale Engage the patient Set specific between session tasks Use activity monitoring and scheduling Use session to review and plan Problem solve difficulties that arise

38. Summary of session BA is a brief treatment for depression.
Patients increasingly engage in activities that help them to re-engage in life despite depressed mood and mood may improve as a result.
Patients are taught to recognize when they are not engaging in an activity because of avoidance.

39. Thank you!