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The Clinician’s guide to supporting the ‘Get back to being you with BA’ protocol
Marie Chellingsworth
Photography by Andy Poplar [Vinegar & Brown Paper] ®
Routine Regulation
The first change method within BA is routine regulation. Routine regulators are markers for the day that help to regulate the body clock and mood, known as ‘zeitgeibers’. Zeitgeiber is a German word that means ‘time-givers’; routines that help the internal body clock to keep in synch with the world around us and the body’s circadian rhythms operating in an orderly way. These can be any external or environmental cues that synchronise our biological rhythm.
social routines and habits in the persons day (for example avoidance behaviours such as not drawing the curtains and sitting in the dark, snacking instead of regular meal times, not completing usual social activities, going to work and the changes to sleeping times and bedtime routine). These depressive behaviours then serve to further maintain the routine marker disruption and worsen mood even more, keeping the person in a vicious cycle of depression.
One example is light, which controls melatonin production, the hormone responsible for sleep, which in turn sets our circadian rhythm. Similarly environmental cues like routine meal times affect appetite regulation and our usual activities undertaken affect activity regulation. We have a dependence on these routines to maintain our mood. Our biological clocks for example, operate according to our circadian rhythm. Triggered by physical zeitgeibers, the light and dark, our dependence on social habits at certain times during the day such as eating, social contact, work and routine. Our bodies become dependent on these routine markers. Since our internal body clock is set by these zeitgeibers, disruption to these routine regulators causes a knock on effect for the person. Good examples of this disruption outside of depression are jet lag or shift working.
Regulation of routine is done as a primary change mechanism within BA to begin to regulate the body clock back into synch. This breaks into cycle of the autonomic physical symptoms of depression such as appetite, sleep and energy and improves the patient’s ability to use activity regulation due to the knock on effect of these symptoms improving.
When someone is depressed, some of the first symptoms experienced are the autonomic physical changes, such as sleep disruption, appetite disruption, motivation and then the behavioural changes in activity that occur as a result of the depression that disrupt usual 13
Routine regulation of daily time givers and cues to synchronise the internal body clock to the world around us, such as our sleep and appetite; are often misunderstood by those without a clear understanding of the BA literature or in-depth training. These can often be confused with routine activities in activity regulation, for example hoovering, or washing up for example. It is therefore important the practitioner understands the rationale for routine regulation, and how this aims to give a daily routine pattern to the patient’s day. Alongside the practitioner being able to understand routine activities which are a part of activity regulation to target avoidance, alongside necessary and pleasurable activity categories. These activities are balanced and spaced out across a week. © Marie Chellingsworth (2020). The CBT Resource.
An example of how to introduce routine regulation to the patient is as follows: Practitioner: “We all have things in our day that give our internal body clock cues and a sense of time. They help to regulate things for us like our sleep, appetite and our mood. When someone is depressed, these usual markers for our day, like our sleep times, the times we eat, as well as what we do during the day, can become disrupted by the symptoms. When this happens, it then further affects our mood, our body clock becomes even more disrupted, further affecting our mood, energy, levels, sleep and activities in a vicious cycle. We can begin to tackle that cycle straight away, by regulating a routine pattern back into your day. This is a helpful way to begin as it does not place too much additional burden on your day when you are feeling depressed. ” Patient: “That makes sense. I will try anything to feel better” Practitioner: “If you think about a usual 24 hour period, usually our daytime is set by light and the night to the dark. It is the light we get in the daytime that helps our body produce melatonin, the sleep hormone. In the evening as it gets dark, the melatonin is released by the body and triggers us to sleep. The pattern of times we usually go to bed and get up are signals to our body clock to sleep and to then wake. You have mentioned your sleep is affected currently. So we can set a realistic time to go to bed by each day and a set time to get out of bed by in the mornings to help with this. We don’t have to make it too early, as I know you said you currently stay in bed © Marie Chellingsworth (2020). The CBT Resource.
most days, but we can set a time that feels OK for you to get out of bed by, and to go to sleep at each for the next week?” Patient: “Yes” Practitioner: “The other important thing to help to do this, is access to light. Sometimes when people are feeling low, they stay inside all day, sometimes with the curtains closed. SO their body doesn’t get the access to light it needs” Patient: “Yeah I am guilty of that....I just sit there if I do get out of bed at all” Practitioner: “What we want to do is when you get out of bed, try to be in natural daylight as much as you can during the day, even if you’re inside the house. Pulling the curtains each day is a routine activity we can build into the activity regulation section. Then in the evening shutting the curtains again and trying to keep light levels dim until your bedtime, to cue your body to prepare for sleep”. Patient: “Yes, I can do that” Practitioner: “We can set those times now on your diary and also set one for routine meal times for the next 7 days. For now, it doesn’t matter so much what you are eating, it is about helping your body to have those routine time cues for your day. We can plan them on your diary where we will plan activities each week. Some people find setting an alarm or reminder for those times on their smart phone or device helpful” 14
Values exercise
The values exercise is an optional scaffolding technique that can be used in a small minority of cases where a patient is really struggling to think of previously enjoyed activities as a result of long term depression or the negative filter of depression affecting their ability to recall more than one or two. It can also be used if a patient is no longer able to complete an activity that was previously enjoyed and it cannot be augmented with Selection, Optimisation and Compensation, for example if they have an injury or illness that prevents carrying out the same activity at all e.g. a loss of ability due to a physical health change or loss of a relationship that was central to the activity, the values exercise can be an optional activity to help generate ideas for the problem list. Due to both time and the fact the evidence that adding in complexity to the BA model, such as additional scaffolding techniques, is no more effective for the majority of patients, this should be reserved purely for these instances where additional help in creating the activities list and hierarchy is warranted. It is far preferential over giving the patient ready created prescribed lists of activities other people may enjoy. These are not recommended in BA. They do not generate 27
natural problem solving, are impersonal and can lead to the patient selecting activities that they are unlikely to engage with or keep doing. To use the values exercise, one activity can be used to generate further ideas that share similar values to the original activity. For example, if a patient used to enjoy cycling and was passionate about it, but can no longer cycle due to an accident or illness, the values they gained from cycling can be used to generate alternative activities. Whilst these activities may not be the same, they are far more beneficial than the alternative of not activating at all or doing activities that are unlikely to be something the patient wants to do or will engage with in the longer term. The practitioner should remember in BA activity is done for the sake of activity to break the cycle, not to generate any pleasure or reward initially. Just doing it is important. The task itself is not the focus, activating with a balance is. Practitioner: “So you mentioned you previously enjoyed cycling before your accident, but you are now unable to cycle for several months. I appreciate that must be very hard given how passionate you were about it” Patient: “Yes, I miss it a lot. I think about it a © Marie Chellingsworth (2020). The CBT Resource.
lot and it really gets me down to be honest” Practitioner: “I can imagine it would and I can see that is hard for you. While we can’t get you back to cycling when you are recovering from the accident for the next few months, getting back to doing activities that are balanced is important. I want these to be things that you can potentially would get something from though, even if they are not the same as we would be doing if you could still cycle. There is a way of doing this called the values exercise if that is something you would be willing to consider doing. It helps us to look at what you value from cycling, what you used to get from it and then to see if these values could be used to fuel ideas for any other activities that incorporate them in different ways for your hierarchy?” Patient: “Erm, yes OK then...” Practitioner: “To do that, we work out what it is you enjoy most from cycling when you were able to do it, what you valued most about doing it?” Patient: “Let me think....I suppose it is being outdoors maybe”
you get from cycling? What made you want to keep doing it?” Patient: “I liked the social side of it, we would all meet up, do a route and then have a drink afterwards, also the time away from home, it cleared my head of all the work stuff and that. Plus the views and scenery were pretty amazing a lot of the time” Practitioner: “Great, so we have a range of things there, getting outdoors, socialising with friends with that shared interest, getting time away from home to clear your mind and also nice scenery were all things you used to get from cycling,...” Patient: “Yes...I hadn’t really thought about it that deeply before, but yeah” Practitioner: “OK, so the next step is to think of some alternative activities that could put you into contact with those values for our list. Whilst not the same as cycling, they are things that you value, so using them as a way of building in activities can be really useful. Lets take the first one of being outdoors........What could you do that is an easier activity and outside...?”
Practitioner: ‘OK, so being outdoors is something we can write down. What else did © Marie Chellingsworth (2020). The CBT Resource.
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