Get Back to being you with Behavioural Activation (BA)

®

Get back to being you with Behavioural Activation (BA)

Marie Chellingsworth

Photography by Andy Poplar [Vinegar & Brown Paper]®

© 2020 Marie Chellingsworth. The CBT Resource ®. 3rd Edition. Last updated May 2020. The right to be identified as the author of this work has been asserted in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. This work is provided under specific license for individual clinical use only by subscribed members of The CBT Resource Annual CPD & Resources plan in 2020/2021. It may be photocopied, printed, and distributed to patients only by the subscription holder for their individual clinical use only in the original binding.

You cannot host this booklet electronically on any website, or pass it onto any other non-subscription holder for clincial use. This condition must be imposed at all times and this work cannot be sold for profit, used for training, edited, copied in full or part, repackaged or amended in any other way without the express permission of the author. The work cannot be circulated for use outside of the license boundaries. It is the responsibility of the service to ensure that staff who support this material are suitably qualified, have specific CPD training in this protocol and receive regular case management and clinical skills supervision.

The main photographs used in this booklet are subject to copyright and the work of Andy Poplar[vinegar&brownpaper] and are used with kind permission (see the about the author section for more information about Andy’s work and his own experiences with anxiety and depression).

Other images are from Unsplash and used with permission in accordance with their requirements.

We would like to thank the focus groups and practitioners who have provided feedback on the development of this workbook design. Your help has been invaluable. The readability score is 11.3 and the Flesch reading ease is 83, calculated independently with Readability Studio©. This information booklet has been designed to meet NHS information Standard Principles and conform to good practice guidelines for self-help and patient information. It is designed to be combined with support by a suitably qualified practitioner who has received specific CPD training in supporting this protocol.

Disclaimer: This material is provided for information, not advice you should solely rely on. It is not a substitute for a clinical assessment, treatment or the provision of advice by an appropriate health professional. If you have questions about any medical matter or think you are experiencing any medical condition, you should consult your doctor or relevant professional healthcare service provider without delay.

It is provided for information purposes only, upon recommendation of and alongside the assessment of suitability and support provided by a suitably qualified clinician. While every reasonable effort has been made to ensure the accuracy of the information, no guarantees, representations or warranties can be given that the information is accurate, free from error or omission, complete or up to date. The assessment and treatment of mental health conditions requires the attention of a qualified medical or mental health professional. We shall accept no liability for any act or omission occurring in reliance on the information or for any consequences of any such act or omission. By using this information, you are agreeing to the provisions of this disclaimer and copyright notice. © Marie Chellingsworth (2020). The CBT Resource.

Contents 1-2 3-4 5-6 7-8 9-10 11 12 13 14 15 16-17 18 19 20-21 22 23 24 25-27 28 29-34 35 36-37 38

© Marie Chellingsworth (2020). The CBT Resource.

Understanding depression Meet Samantha & Mike My own vicious cycle Setting your goals Building motivation How BA can help The 6 steps of BA Step 1: Planning your daily routine Step 2: The activities you are avoiding Step 3: Your BA Hierarchy Step 4: Planning your first week of BA Your week 1 BA diary Tips from Samantha and Mike Step 6: Reviewing your first week of BA Your plan for week 2 Your week 2 BA diary Reviewing week 2 and planning week 3 Blank BA diaries Carrying on with BA Staying well: Your BA first aid tool kit Where to get more help Your notes About the author and Andy’s images

Understanding depression

Low mood and depression can affect anyone, at any time. 1 in every 6 people report a common mental health problem like depression or anxiety each week in England.

Depression is a commonly experienced problem worldwide. It affects people of all ages and backgrounds. The good news, is that there are treatments that can really help. Behavioural Activation (BA) is recommended to treat depression in national clinical guidelines. This is because of its large evidence base. It is a form of Cognitive Behavioural Therapy (CBT). It helps people to manage their symptoms and get back to feeling like themselves again. You can learn more about BA and how to use it in this booklet.

When you have depression, it can feel like you are living on auto-pilot.

Life is still going on around you; but you don’t feel part of it. You don’t have the energy or motivation to join in. Depression can happen after experiencing a big life event, such as changing jobs, becoming a parent or retiring for example. Sometimes people may experience depression without any particular trigger. Feeling depressed is a personal experience, but there are some common shared symptoms:

• Feeling down for most of the day, nearly every day

• Decreased interest or pleasure in your activities

• Changes in your appetite

• Sleep problems (like waking up early, or not being able to get off to sleep)

• Tiredness and loss of energy nearly every day

• Feeling guilty or worthless

• Struggling to concentrate • Noticing more negative thoughts and going over them in your mind (called rumination)

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The symptoms of depression can affect your life in a range of ways.

They disrupt your usual routine. Things that give your day structure fall away. Sleep and energy levels are affected, making you feel more tired and lethargic. Your appetite and the types of foods that you eat can change. It can affect your concentration and motivation. Your work, studies, social life and relationships with those close to you can all be impacted as a consequence. Negative thoughts and your physical symptoms of depression can make it hard to get back to doing things you used to do. When you do try them, they are not as enjoyable and can feel overwhelming.

Understandably, as a result of the symptoms of depression, people begin to avoid things that bring on more symptoms and negative thoughts. For example, if you have plans to meet a friend, but are feeling exhausted in the morning and haven’t slept well, you might cancel your plans and go back to bed. In the short term this avoidance gives you some relief from how you are feeling. In the longer term though, it takes you away from even more things that give life structure and routine. It takes you away from things you used to enjoy and the social aspects of life. As a result, mood can spiral further down in a vicious cycle of depression. BA can help to break into this cycle, building back a structure and routine in a way that feels manageable to you.

There is no set way to use this booklet. You may want to read it all first and then come back to complete the tasks. Others prefer to read it as they go, completing the tasks along the way. Two people who have used BA share their experiences in the booklet, Samantha and Mike.

While their situations may be different to your own, the symptoms they experienced will be similar and they share how BA helped them.

Just go at a pace that suits you. The important thing is to put what you learn about BA in the programme into action in your daily life. Your practitioner will help you to make a weekly plan to use BA that feels realistic and achievable. © Marie Chellingsworth (2020). The CBT Resource.

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Meet Samantha, she developed depression after going to University.

She struggled to attend regular appointments due to being away during term time and back at home in the holidays so Samantha used BA, with regular weekly support over the telephone.

I was so tired all the time. I couldn’t concentrate on my lectures. I wasn’t sleeping well and lost my appetite. I just couldn’t be bothered to do things. Everything seemed hard. I was missing home, my family and my old friends. It was my flat mate who first became worried about me. She encouraged me to go to my GP. I felt hopeless and thought that I was letting everyone down. Especially my parents who were paying for my uni fees and rent. I felt so guilty and ashamed, I stopped calling them or answering their calls. Using BA and getting back into a routine really helped, then the other things fell back into place bit by bit. Taking the first step was hard, but I am so pleased I did. I got my degree and am now on my teacher training too, things do improve.

Physical symptoms Tearfulness Lacking in energy Sleep problems Struggling to concentrate Reduced appetite Low motivation

Behaviours Not attending lectures Napping in the daytime Avoiding seeing my friends or socializing Shutting myself in my room Waking early and difficulty getting to sleep Not answering the phone or ringing my family

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Altered thoughts “I shouldn’t be at university” “I am not good enough” “I am letting everyone down” “Everything is too hard” “I am a failure” “I can’t be bothered”

© Marie Chellingsworth (2020). The CBT Resource.

Meet Mike, he became depressed when facing possible redundancy from his job as a data analyst.

Mike is married to Alice, with a young daughter Tia. He used BA after referring himself to the service.

Work was really getting me down and I felt hopeless about it all.

Several times I phoned in sick. I was struggling to concentrate and get things done. Even simple things that I found easy before felt hard.

We could not afford for me to be made redundant, and it felt like an axe over our heads. I wanted to work hard and prove I should be kept on. I had stopped doing the things we used to enjoy as a family. I was so tired and really irritable all the time. I felt they would be better off without me bringing the mood down. I stopped playing rugby and going out for drinks with friends. I had become stuck in a vicious cycle.

BA really helped me to feel like myself again and get things in balance.

Physical symptoms Irritability Trouble falling asleep and waking up too early Low motivation Concentration problems Aches and pains Headaches

Behaviours Missing work.

Not going out with friends.

Not exercising or playing rugby.

Not eating properly.

Bringing work home to try to catch up

© Marie Chellingsworth (2020). The CBT Resource.

Altered thoughts “I won’t catch up, I am a failure” “I am bringing everyone down” “There is no point doing anything, I won’t enjoy it”

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My own vicious cycle Now you have read about depression and how it affected Samantha and Mike, take a moment to reflect and think about your own symptoms of depression and how the cycle is affecting you. Put your symptoms in the diagram below. This will help you see how they are interacting with each other and then make a plan to break the cycle using BA. List the symptoms you have noticed in each of the areas. Try to write the thoughts as actual thoughts, like Mike and Samantha above. After that, turn the page to set your own targets for feeling better.

My Physical Symptoms

My Altered Behaviours

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My Altered Thoughts

© Marie Chellingsworth (2020). The CBT Resource.

Mike: “I wasn’t sleeping very well and was tired and irritable. I was thinking negatively about my work and not wanting to do things I normally wanted to do. I thought that I was a failure and bringing people down. I ached all over, had headaches and felt exhausted. Even physical things such as aches and pains can be connected to your mood.”

© Marie Chellingsworth (2020). The CBT Resource.

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Setting your goals Imagine into the future. The symptoms you listed in your vicious cycle have improved and you feel better again. Your routine for each day is back on track. What will life be like for you when these symptoms improve? What things that are important in your life will you be doing again?

Answer the questions below to help you to set your goals for using BA.

Where would you be going?

(For example, I would be socialising with friends, I would be going to the gym again. I would be back at work etc.)

What would you be doing?

(For example, I will be able to do the food shop on a Sunday. I will be cleaning each week. I will be spending more time with the children having fun etc.)

Who would you be with?

(For example, I would be spending more time with my flat mates going to the cinema, I would be spending more quality time with my husband, I would be back at the social club etc.)

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© Marie Chellingsworth (2020). The CBT Resource.

The next step is to turn these things into goals. Then to spot the steps you can take towards this in the short, medium and longer term. Breaking things down really helps us to get where we want to be. Think what is realistic for you based on where you are now.

Goal 1: for example, see my friends once a week.

Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 2: for example, to get a good nights sleep and wake refreshed Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

Goal 3: for example, have regular meal times each day.

Things I can do towards this goal in the next couple of weeks: Things that I can do towards this goal in the next month: Longer term things I can do to work towards this goal over the next six months or so:

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Building motivation Thinking about the problem and beginning to work on the goals you have set. On a 0-100 scale rate: How much impact does the problem have on my life currently?

0

50 100 not at all

affects everything

How important is it for me to reach my goals?

0

50 100 not at all

totally important

How willing and able am I to set aside enough time to get better?

0

50 100 not at all

totally willing

How much of a priority is getting better for me at the moment?

0

50 100 not at all

complete priority Activity: Some people find it helpful to complete the following exercise. This is useful if you are struggling with your motivation because of how you are feeling. Write two short letters short letter to yourself.

In the first letter, you are writing to yourself now as if it is five years into the future and you haven’t set aside the time to get better or improve your symptoms. What would life be like? What would you like to say to your current self to get you to set some time aside for feeling better?

Next, in the second short letter to yourself. It’s five years in the future and you have made the changes to break the vicious cycle and feel better. How pleased are you?

What changes has it opened up in your life? What would you be doing? Where would you be going? Visualise your life improved as a result. Turn to the next page to get going towards that now. Every step is a step in the right direction.

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Samantha: “It is important to think about where you want to be in the future when you feel better. I didn’t realise all the things I had stopped doing until this task. I didn’t want to go out, I stayed in bed or on the sofa with the curtains closed and wasn’t socialising. I wasn’t eating regularly. No wonder I had no energy. It was great to make a plan to build back in a routine and things I valued, like listening to music.

What things are important to you?”

Mike: “This was very powerful. It helped me to see that there was a way forward.

I had to take the chance. I could help myself using BA, which I liked. I could work towards things that I used to enjoy. I could imagine the look on Tia’s if we did more together again as a family and that helped motivate me” © Marie Chellingsworth (2020). The CBT Resource.

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How Behavioural Activation (BA) can help When you have low mood it can feel hard to do things that you used to take for granted.

Negative thoughts can stop you in your tracks. Things take lots more effort. You feel more tired and notice more negative thoughts when you try. Understandably, you begin to reduce or avoid doing things that make you feel that way or bring on your symptoms.

In the short term, withdrawing and avoiding gives you some temporary relief from the symptoms of depression. You stop doing even more of the things you used to enjoy or that take too much effort. In the longer term though, avoiding these things makes your mood worse. It takes you away from the things that you value in your life. Your daily routine gets more and more disrupted. You get caught in the vicious cycle of low mood. The good news is that the cycle can be reversed, using BA. BA will help you to build a balanced daily routine and will get you back to doing the things that you want or need to do each week. BA will also help you to have fewer negative thoughts as your mood lifts and you focus upon the BA tasks. Instead of your thoughts and feelings controlling what you do, you regain control over them.

At first, the activities may seem harder than they did before. You may feel more tired after them or have more negative thoughts initially as the cycle reverses. This is to be expected and will improve. You may also not be able to complete as much as you did before. This is totally normal and the aim of BA isn’t to do a certain amount of a task or complete an activity.

In BA you do the activity for the sake of treatment and not to complete it. You stop when you get to the point you could do the same amount again. In BA you do the activity according to your plan, not letting negative thoughts or physical symptoms put you off activating at that time. You stop the task or activity when you still have half an energy tank left and could do the same amount of it again. This is so you don’t get an unmanageably high level of symptoms as the cycle reverses, which would be too exhausting or overwhelming. By stopping when you could so the same amount again, you are working with the current level of your mood and symptoms; and, as your mood lifts the amount you can do to reach half a tank of energy left will increase too.

Give it a go, you can do this!

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The 6 Steps of BA You work to the plan and carry out the activity despite any negative thoughts or physical symptoms that may try to put you off. Initially, you may notice your symptoms increase slightly as you begin to reverse the cycle. Remember that is to be expected and only happens for a short while before they begin to go down and your mood lifts.

1. Set a daily routine: You set a realistic time to go to bed and a wake up time by which you will get out of bed by each day and regular meal times for the next 7 days to structure your routine for the day 2. Write a list of the routine, necessary and pleasurable tasks that you have reduced or are avoiding as a result of how you are feeling 3. Build a hierarchy of routine, necessary and previously pleasurable tasks: from easier to more difficult ones 4. Select 1-3 activities from the easier list and spread them out across the week. Aim for a balance between activity types. Self care and routine building tasks should be prioritised first 5. Put your 7 day plan for balanced weekly activities and your routine for each day into action 6. Review your progress and set your next 7 day BA plan.

You keep following the steps of BA until your mood has lifted and your physical symptoms have improved. As you keep repeating the steps of BA each week, the symptoms begin to lift in a short space of time. To help with this, you start with easier things first. Then, you build up to more difficult tasks at your own pace.

You take it in gradual steps and don’t do too much of any planned activity that could feel overwhelming. In BA you do the task for the sake of treatment, not to complete it. You stop when you still have half an energy tank left at the point where you could do the same amount again.

© Marie Chellingsworth (2020). The CBT Resource.

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Step 1: Planning your daily routine & structure We are creatures of habit. Our body clock and overall wellbeing relies on routine as a marker for our day. The things we do, like eat around the same time, being active, and our sleep help our body to function properly and synchronise to the 24 hour cycle.

When we are depressed, our normal body clock pattern and routines can become quickly disrupted. We usually wake when it is light, having access to daylight in our waking day. The body builds up the sleep inducing hormone melatonin we need at night, through our exposure to light in the day. Then, our body knows it is time for sleep when it is dark and releases the melatonin to help us to sleep. As a result of the changes to our activity, we can affect the balance of these routines even more. For example, we may not be as active, eat irregularly due to appetite changes, we may keep the curtains closed, stay in bed and spend less time outside the house and active. This can throw out your body clock and keep you in the vicious cycle of depression. Building back a routine in BA and gradually increasing activities can be a very powerful way to break the cycle of depression. They are also small daily changes that can be made without adding too much burden to your day when you are already feeling down and having physical symptoms of depression.

Your sleep routine: Time to go to bed: Set a time that you will go to bed by each evening, based on how you are sleeping now. If you are not sleeping until midnight, but going to bed at 10pm, go later to increase the chance of you feeling drowsy tired and drop off more easily.

This will improve your sleep association with your bed.

Time to get out of bed: Set a time to get out of bed each day. Be realistic to start with, set a cut off point for when you will get out of bed, despite how you are thinking or feeling at that time. If you need to be out of bed for a certain time to get to work or your studies, use that as your cut off. Each morning, you stick to that plan, despite how you are feeling when you wake up, how well you slept that night, or any negative thoughts you are experiencing. It is also important to not nap during the day, as this will affect your body clock for sleep that night. This will help you to re-regulate your body clock.

Write the times you plan on the diary on page 18.

Your appetite and routine for meals: When you are depressed, one of the early signs

of depression is changes to your appetite. We feel hunger based on our body clock sending a signal that we should expect food. Our body bases this on the routine times it is used to getting food each day. When you feel depressed, the routine times you eat can get disrupted, eating is no longer as pleasurable and it can feel demanding to cook. This further impacts on your appetite and mood. To get this back into a routine, you plan times you will eat each day.

Initially, it doesn’t matter what you eat, so much as keeping the time of day the same to get your routine back. You can tackle cooking and eating differently through the next step of BA, your activities.

Write the times you plan on the diary on page 18.

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Step 2: The activities you are avoiding Now, in the spaces below, make a note of any routine, necessary and previously pleasurable activities that you have stopped or are avoiding as a result of your mood and symptoms. Don’t worry for now how many things are on your list or how hard they would be to get back to. Just write them all down, as many activities that you can think of. You won’t start with more difficult activities right away. BA is graded and you start with easier things that are manageable, by putting them into a hierarchy in step 3.

Routine: Routine tasks are the every day things that have to be done that you are avoiding, this

includes things like housework, emptying the bin or dishwasher, doing the laundry, paying bills, mowing the lawn etc.

Necessary: Necessary tasks are those activities that if not done by a certain deadline there would

be an immediate health or financial consequence e.g. like taking your insulin if you were diabetic or responding to an eviction notice for not paying the mortgage or rent. It may be that you do not have any necessary tasks at the moment, or that you don’t have a necessary task each week you do BA.

Pleasurable: Pleasurable tasks are things that you previously enjoyed, but are no longer doing as a

result of your mood. It may be that these things give you little, if any pleasure at the moment, but doing them is part of your usual routine prior to feeling this way. This includes things like hobbies and interests, playing, activities or speaking with your children, seeing friends and family. watching films, undertaking sport or exercise or walking the dog for example.

© Marie Chellingsworth (2020). The CBT Resource.

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Step 3: Your BA hierarchy Next, take the items from each section of your list and grade each section into easier to more difficult to do, writing them in the hierarchy below.

You need a mix of routine, previously pleasurable and any necessary things in each of the steps.

If a task feels too difficult, try and break it down into easier steps. Then you can begin to plan your first 7 day BA plan and put your BA skills into action to break the cycle!

My BA Hierarchy Most difficult...

More difficult...

Easier...

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© Marie Chellingsworth (2020). The CBT Resource.

Step 4: Planning your first week of BA Remember to add a balance of routine and pleasurable tasks into your BA plan. These need to be practical and realistic with your current mood level.

You can then begin to plan in your first BA tasks from the easier section into your BA diary to do in the next 7 days. Aim for 2-3 activities across the week in your first BA week from your easier section, along with your daily routine eating and sleeping times you set. Each week you work up the hierarchy and can adjust it as you go along. When you are feeling low, everything can seem overwhelming initially. BA helps to break things down into manageable steps. Remember a true necessary task is one where there would be an immediate health or financial consequence if you don’t do it that week. If you have a necessary task, break it down across the week to make it manageable and balance pleasurable easier tasks in too. Keep to your plan despite how you are thinking or feeling. Make sure when you experience negative thoughts or physical symptoms of depression, they don’t stop you choosing to activate. Work to the plan, not your mood.

Each day, use your plan to guide when you will get up and when you will go to bed. Also plan for when your meal times will be. It is less important (for now) what you eat, but eating at routine times will help to target the physical symptom in depression of appetite changes. You will also add in some easier tasks in a balanced way across your week.

You may have been doing these activities, sport or exercise before your low mood and want to get back to doing it as you did it before. Think about a sportsman who hasn’t trained for a while due to an injury. They will need to build their training back slowly. They won’t be at the same level of fitness. That comes back through doing it and with time. Doing more doesn’t make BA work quicker. In fact, it can give you back too many of the symptoms of depression all at once. That is why things are graded and you stop when you could still do the same amount again.

Balance your tasks out across the week from each category. Break tasks down if they seem too hard and put these revised steps on to your hierarchy. Remember, you do not have to complete the task in full,or for a certain amount of time. For example, if your task is to wash up, you don’t wash up until everything is done, or for specific amount of minutes to complete your BA activity. You stop at the point where you could do the same amount you have just done again. You use your energy level as a guide and stop when your energy tank is still have full.

You may not do as much of it as when you did it before you felt this way. You may also notice an increase in negative thoughts and symptoms at first, before they get better. This is normal and to be expected. Remember, stop when your energy tank is still half full. BA is activity for the sake of treatment, not to complete anything or do it in the same way before you were depressed. This helps you to not get overwhelming symptoms of depression afterwards and to balance your energy and routine across the week.

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© Marie Chellingsworth (2020). The CBT Resource.

Where to place activities in your diary to work with your body clock: • Aim for balance across the week. You don’t need an activity planned in every day, unlike your daily routine for eating and sleeping. Balance your hierarchy activities out across the week. 1-3 activities per week initially is perfect. Gradually increase this as your mood begins to lift. Don’t do too much. Doing more won’t make your mood lift more quickly, it can have the opposite effect and overwhelm you with symptoms • Try to plan to do activities that require concentration in the mornings where possible as this is the best time for concentration • Remember to get access to natural daylight between 11-3pm to help your body to produce the sleep inducing hormone melatonin for a good night’s sleep. If you can’t get outside, get near the window. Make sure you open the curtains in the morning as an easier first step. It’s a small thing that can easily slip when your mood is low.

• In the evenings, try and get into a routine before bed. Close the curtains and dim the lights.

Do relaxing activities. The routine and darkness helps your body to know to release melatonin and prepare for sleep. If you struggle with dropping off to sleep a warm bath can help, milky drinks without caffeine can too. Warm feet can also help you to drop off to sleep more easily.

• Activities that involve exercise are best placed in the afternoon, so a walk then is a great way to get outside and natural daylight as well as increase your activity levels. If your task involves exercise, schedule it in for the afternoon where possible.

Once you have written down your BA plan on the diary, think if there is anything external that could get in the way of you carrying it out. Things like a neighbour turning up unannounced at that time or a childcare issue. If that happens, when else will you carry it out. Is there anything internal that could stop you? Remember internal thoughts and feelings may try to stop you in your tracks, in BA you stick to the plan to act your way out of depression and break the cycle. So stick to the plan despite any internal thoughts or feelings.

Remember that in BA you do the planned activity on your diary, despite how you are thinking or feeling at that time - you act against your depression symptoms. The aim isn’t to complete an activity, like washing up for example, or to plan to do it for a certain amount of time. In BA you stop when you feel you could do the same amount again, when you feel your energy tank is still half full. You do the activity for the sake of treatment, not to complete anything or spend a certain amount of time doing it. BA works by breaking the link between how you are thinking and feeling affecting what you do and by regulating your routine structure for your day back in.

Now it is time to carry out your BA plan for 7 days! Good luck with your first week. You can do this! Remember every step is a step in the right direction. Come back to review how it went in step 6

© Marie Chellingsworth (2020). The CBT Resource.

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© Marie Chellingsworth (2020). The CBT Resource.

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Tuesday

Wednesday

Thursday

Friday

Necessary tasks that I need to complete:

Routine for meal times this week:

Monday

Routine plan for going to bed this week:

Routine for getting up this week:

My Behavioural Activation Diary

Saturday

w/c

/

Sunday

/

Tips from Samantha and Mike

Samantha: “As you go forward with your BA planning, begin to build in a pattern of activities.

When I did a routine task such as doing the laundry, I made sure I did a previously enjoyable activity after that. For example, I had a cup of tea with my friend. This helped me 17 to build back in a routine pattern of planning my days. I didn’t enjoy things straight away, but having done them helped me feel in control and then the feelings came back as my mood lifted. Trust the process” Mike: “Having set meal times is helpful. I found I was not eating regularly or eating the right things. What you eat may not need to change; or, may not change straight away based on other things on your plan. As you go on with BA you may want to change what you are eating. For example, if you are not cooking as much as you did before, like me, have cooking on your BA plan. You can then build up to this. Don’t feel under pressure to do something straight away. I made sure I broke the task down to make it feel easier. Stay positive - you can help yourself get better by using BA!” Samantha: “Everything seemed hard at first. I had to really push myself to not let the thoughts about it or my energy levels stop me. One thing I did from the start, was get into a routine of opening the curtains every morning and then closing them in the evening. A small thing, but it did make me feel more awake and to feel ready for bed in the evenings. I knew access to light would help, so this and just sitting outside with a cup of tea were small things I could do straight away, when even going for a walk seemed too difficult” 19

© Marie Chellingsworth (2020). The CBT Resource.

Step 6: Reviewing your first weeks progress Once you have completed your first week of BA the next step is to reflect on how things went. This section will help you check your progress. Use the questions below to complete your review of your first week.

Your routines: Appetite: Each day you had set times for your meals to begin to regulate your appetite. How did it go?

• Noticing that you are hungry just before your routine time is a sign that this is improving. This takes time. Remember eating in this way will help to regulate your appetite and blood sugar, giving you more energy and will also have a knock on effect on your mood over time.

• While the cycle reverses, food may not seem as rewarding or enjoyable, it may not give you the same sense of satisfaction as it did before. You may not look forward to eating or derive the same taste from it. You may also find yourself wanting to graze and snack on comforting foods at other times. Try to keep to the times you have planned for eating while doing your BA treatment.

• These appetite changes should improve as your mood lifts. Keep with the plan to give structure to your day and help to improve how you feel.

Your sleep: Each day you set a time to get up and a time to go to bed to build a routine for sleep. Getting your sleep back into a routine really helps to lift your mood and improve how you are feeling in each area of the cycle. So, how did it go?

• Did you stick to your planned times this week, if yes, what did you notice? If not, what got in the way?

• Did you wake feeling refreshed on any of the days?

• Did you fall to sleep within 20 minutes of getting into bed?

• If you lay in bed longer than your set wake up time, what did you notice in terms of your thoughts and how you were feeling? What does this tell you for next time?

Don’t worry if you didn’t sleep as well as you had hoped yet, it takes a while to build back a good sleep routine and break the cycle. Trust the routine and keep doing sleep promoting activities in your routine before bed. Remember the key to improving your routine for the day is to be consistent with the times each day. Avoid daytime napping or staying in bed after your wake up time.

Next, answer the BA activities review questions on the next page.

© Marie Chellingsworth (2020). The CBT Resource.

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Your BA activities review Look at each task you had planned in one by one and consider these questions to review them: • Did you complete it as planned? If not, what stopped you? Was it something external to you, or something internal like an off putting thought or your symptoms?

• If you did, the task, how did the task go?

• What did you notice before you did the activities? What did you notice after you did it?

• How did you feel for the rest of the day after doing the task? Did doing it impact on you the following day?

• Looking at your diary, on a day when you had no planned activity in, did you feel different to the days you did?

• When you did the task, how was your negative thinking? When you had no tasks planned in, did you notice you had more negative thoughts that day?

• What have you overall learned from carrying out your BA activities?

• What do you think you need to do next week?

Mike: “The first week was definitely the hardest for me. One of my activities was to have a coffee break with my work friend. I nearly didn’t go through with it. My mood on the day was very low and I couldn’t face coming away from my desk and falling further behind. I had horrible negative thoughts and was really struggling to concentrate. I thought ‘What is the point, I will be lousy company anyway’ and felt like a failure for struggling with a simple task.

My thoughts and feelings of depression were affecting what I felt I should do. I realised I needed to act against this and do it anyway. It was hard though to take that first step, but I am so glad I did” 21

© Marie Chellingsworth (2020). The CBT Resource.

Your plan for week 2 Now you have reviewed your first week! It is time to make a plan for week 2.

To plan for your daily routine for next week: Appetite: Think about your routine for meal times over the coming 7 days. Try to choose times that fit with any commitments you may have, but allow you to meet a routine pattern. Be as consistent as you can about the times you eat.

Sleep: Adjust the time you go to bed if necessary, depending on how well you slept. Keeping your wake-up time the same each week. If you found it took a long time to get off to sleep for example, then set a time to go to bed later for this week, nearer to the time you dropped off. For example, if you went to bed at 12am but didn’t sleep until 1am, adjust your time to go to bed this week to 12.30/12.45 to help you to feel drowsier when you go up to bed.

If you went to bed and slept well, you can adjust the time you go to bed in 30 minute stages, to get closer towards the bedtime you would like, to get between 7-9 hours of sleep. For example, if you went to bed at 12am and woke up at 6 and managed to sleep from 12.20-6 then you can push the time you go to bed back to 11.30. You keep adjusting your time to bed each week, until you achieve between 7-9 hours of sleep and wake feeling refreshed, at your chosen wake up time.

Choosing activities to do for week 2: Go back to your hierarchy, choose some new activities to do for this week. Remember the BA tips and what you have learned from your first week of BA. Choose a balanced mixture of routine and pleasurable tasks that are easier.

Remember to spread these out across the week. If there is a necessary task you need to do by this week or there will be a consequence, add that in the diary. Break the necessary task(s) down into easier steps if they seem too difficult. Remember stick to the plan and not let your mood or thoughts put you off.

Samantha: “I was honestly tempted to give up after the first week. I was disappointed I didn’t feel better yet.

I was exhausted. I couldn’t imagine feeling any better and had so many negative thoughts. The support from my Practitioner and re-reading the booklet helped me to see that was my depression talking and I was expecting the cycle to reverse too soon, I needed to trust the process. It works!” © Marie Chellingsworth (2020). The CBT Resource.

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© Marie Chellingsworth (2020). The CBT Resource.

Tuesday

Wednesday

Thursday

Friday

Necessary tasks that I need to complete:

Routine for meal times this week:

Monday

Routine plan for going to bed this week:

Routine for getting up this week:

Week 2: My Behavioural Activation Diary

Saturday

w/c

/

Sunday

/

Review week 2 and plan for week 3 Use the review questions from week 1 to review your second week. When you have completed your second review, it is time to plan for your third BA week.

Activities: Keep working up your hierarchy of activities and choose a balance of activities across your week. Break down any harder tasks into steps. Remember you will do the activities according to the plan, not any thoughts or feelings at the time that may try to put you off.

Remember the aim of BA is to begin to build back a routine pattern of activities. After a routine or necessary task, it is good to make the next planned activity a pleasurable one. After a pleasurable one, getting a routine task like a chore done for example.

Appetite: Continue to be as consistent as you can about the times you eat. Set your times for your next 7 days. Try to keep them as near as possible to week 3, working around anything that may affect these for you.

Sleep: Keep your wake-up time the same. If you went to bed and slept well, you can adjust the time you go to bed in 30 minute stages, to get closer towards the bedtime you would like regularly to get between 7-9 hours of sleep.

Remember to stick to the plan. Don’t let your mood take you off track.

Every step is a step in the right direction to reverse the cycle. You may not notice the improvements initially. Give it time and go easy on yourself. You can do this!

© Marie Chellingsworth (2020). The CBT Resource.

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© Marie Chellingsworth (2020). The CBT Resource.

Tuesday

Wednesday

Thursday

Friday

Necessary tasks that I need to complete:

Routine for meal times this week:

Monday

Routine plan for going to bed this week:

Routine for getting up this week:

My Behavioural Activation Diary

Saturday

w/c

/

Sunday

/

© Marie Chellingsworth (2020). The CBT Resource.

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Tuesday

Wednesday

Thursday

Friday

Necessary tasks that I need to complete:

Routine for meal times this week:

Monday

Routine plan for going to bed this week:

Routine for getting up this week:

My Behavioural Activation Diary

Saturday

w/c

/

Sunday

/

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© Marie Chellingsworth (2020). The CBT Resource.

Tuesday

Wednesday

Thursday

Friday

Necessary tasks that I need to complete:

Routine for meal times this week:

Monday

Routine plan for going to bed this week:

Routine for getting up this week:

My Behavioural Activation Diary

Saturday

w/c

/

Sunday

/

Carrying on with your BA activities Carry on with your BA until you feel you are no longer struggling with your low mood symptoms.

There is no set answer of how long you should be carrying on with BA. Both Samantha and Mike differed in how long they carried on with BA. Usually improvements can be seen within 4 weeks, but each person is different.

Look at whether your symptoms are improving. Go back to the vicious cycle you completed at the start • Have they improved since you started BA? • How are your physical symptoms and behaviours?

• What changes have you noticed?

• Are you sleeping between 7-9 hours a night?

• Do you feel your appetite has returned?

• Is your day rewarding? Do you feel that you have a good mix of activities that you are completing?

How far have you moved towards your goals?

• Have you met any of these?

• If not, are you close to meeting any?

• Are there any which need more work? If so, what are you going to do and when are you going to do it?

Remember, to pay attention to the physical symptoms like your appetite and sleep. Your low mood may have improved but are you still experiencing concentration, sleep or appetite problems? This is a sign to continue with the elements you need of BA until these have also improved. When you feel you are ready, you can move on to the relapse prevention section.

© Marie Chellingsworth (2020). The CBT Resource.

“Mike: It takes time to reverse the cycle. It took me a few weeks and then I started to feel better, but I felt a bit worse initially.

It was my concentration that was probably the last thing to improve. You want to make sure your symptoms have improved fully and you have met your goals. I felt I had my mojo back, so I checked these before I decided whether to stop my weekly BA plans or not.”

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Staying well: My BA First aid kit It is great news that you have completed your BA treatment and feel better!

Congratulations! You will have worked hard to get to this point. By putting your BA skills into action, you have helped yourself to feel better. Now, it is time to think about staying well in the future and managing your mood long term. It is important to know when you may be having a lapse or a relapse, your early warning signs and what to do if you need to put your BA skills into action again.

Can I really go it alone? or will I become unwell again?

I would like to keep working on feeling better

Am I ready?

How can this help me to face the future and keep well?

I feel so much better! But will it come back?

Will I feel down again?

It is normal for our mood to change day to day. Often more than once in a day, depending on what happens to us! We all have times when we feel down or anxious for a few hours, or even a few days at a time. We also all have negative thoughts and worries, even when we are not depressed or anxious. We just don’t pay so much attention to them as they pop in and pop back out of our minds again. What should you do you do when you have a day like this? Try not to let how you are feeling, or any worries affect what you do. Keep to your routine structure in your day and any activities you had planned. Avoidance and disruption to your routine is when that vicious cycle can take hold again. It is part of everyday life to feel down or anxious from time to time. Be kind to yourself if this happens. Don’t put yourself under too much pressure that your mood has always got to be positive – you will have days you don’t feel as positive as right now. This is OK, we all do. That doesn’t mean you are back where you started from. You also know now what you can do to improve how you are feeling and not let a vicious cycle take hold again.

What is a lapse?

Sometimes, you can lapse back into old ways for a few days. For example, you may avoid things because of thoughts or feelings. A lapse does not mean that you have relapsed.

Spotting it means you can act to break the cycle before it takes hold. Recognise a lapse for what it is. Try not to worry that it is a sign that you have gone back to square one. It isn’t! If you spot this happening, it’s a sign to put your skills into action again.

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What is a relapse?

A relapse is when you start to feel the way you did before. Your physical symptoms and negative thoughts may return for several days in a row. If this should happen, you have the BA skills to put back into action again. That should mean that the problem doesn’t get as bad or last as long. Completing this section can help you to spot early warning signs before that vicious cycle has a chance to take hold again. © Marie Chellingsworth (2020). The CBT Resource.

My early warning signs

Make a note of the things that you noticed first when you were becoming depressed. How did it affect you physically? What were you doing, or not doing as a result? How did it affect your thinking? Sometimes people around us can notice these things before we do. Ask those close to you what they may have noticed first. Looking back at your vicious cycle from the start of your BA can also help you with this.

These are things to look out for as early warning signs in the future. Remember though, that you may have some of these symptoms as part of a normal mood pattern. If they are affecting how you are feeling and what you are doing more days than not, it is time to act and put your BA skills into action again.

© Marie Chellingsworth (2020). The CBT Resource.

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My regular review

Reflecting on how you feel now your mood has improved is an important step in staying well.

Write yourself a letter about how far you have come, how you are feeling and how - and what you did - that made that happen. What will you now do as a result, what are you looking forward to? Then, pop it into an envelope and address it to yourself. Put a reminder on your calendar or on your phone. This can remind you to open it and enjoy reading it again in 3, 6 and 9 months from today’s date. Once opened, reflect on how you are feeling. Also reflect on the impact that making the changes you have put into place has had on your life since. Then re-seal it and put it somewhere safe you will remember for next time! You should take out your letter and read this again if you notice any early warning signs. This will motivate you to put your BA skills back into action. This will help prevent your early warning signs from getting worse.

Remember, you have helped yourself before. You can do it again!

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© Marie Chellingsworth (2020). The CBT Resource.

My regular review Keeping check on my mood How has my mood been this month?

Have I had any of my early warning signs?

YES

For how many days?

NO

Reflect on the progress you have made since your last review and take a moment to think about what you would like to do in the next month to keep moving forwards

Am I avoiding things because of how I am feeling, having negative thoughts that are affecting what I am doing, or have I been doing things to feel better, that only work in the short term?

YES

If yes: Do I need to put my BA skills back into action?

If so, what am I going to do and when am I going to do it?

© Marie Chellingsworth (2020). The CBT Resource.

NO

Look through your BA first aid kit to keep your skills fresh for the future and then plan a new review day

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My BA mood first aid tool kit Think of your BA skills as a first aid tool kit for your mood. They are always there if you need them.

You just need to remember how to use them and to keep your BA skills fresh.

What are the key points of BA and how you use it? Remember you can go back to the pages in this guide at any time to refresh your understanding. This is a great way to make sure you know what you need to do, if you need to put the skills into action again. Even if you are feeling well, a review day is helpful once a month to spot any early warning signs. Ideally, plan 6 months ahead of dates now and pop them in your calender or on your phone to remind you.

Date of my next review day. Put this on your calendar or somewhere you will see it as a reminder.

Date of review 1:

Date of review 2:

Date of review 3:

Date of review 4:

Date of review 5:

Date of review 6:

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© Marie Chellingsworth (2020). The CBT Resource.

“Mike: “I was a bit worried that I would end up getting depressed again in the future without support.

Chris my Practitioner said to me ‘Mike, I only showed you the road to take and you took it, you did all the hard work to get to your destination.

You can always do it again if you need to.’ That really meant a lot to me and made me realise, I can do it.

My mood isn’t always positive, I have ups and downs of course, but, I know the warning signs of a cycle forming and I take action early. My reviews help me to stay confident and spot any patterns” © Marie Chellingsworth (2020). The CBT Resource.

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Where to get more help Emergency help If you, or someone you are worried about, need support in an emergency situation, do not put off getting help.

The following can be used in an emergency: • • • • •

Emergencies: 999 An Emergency appointment with your GP Fast medical advice in a non-life threatening situation: 111 Samaritans: 116 123 (24-hour service) SANEline: 0300 304 7000 (4.30pm-10.30pm every day)

Remember, do not be afraid to get help. Feeling this way doesn’t last forever and there are things that can be done to help!

Below are some useful web links with good quality information for anxiety and depression and what treatments are recommended if you want to learn more:

Useful websites on depression and its treatment • The NHS: https://www.nhs.uk/conditions/clinical-depression/ • The National Institute for Health & Care Excellence depression information: https://www. nice.org.uk/guidance/cg90/ifp/chapter/About-this-information • The Royal College of Psychiatrists: https://www.rcpsych.ac.uk/mental-health/problemsdisorders/depression • MIND The mental health charity: https://www.mind.org.uk • The Mental Health Foundation: https://www.mentalhealth.org.uk/a-to-z/d/depression Other useful helplines: • National Domestic Violence Helpline: 0808 200 0247 • Forced Marriages Unit: 0207 008151 • Support for Lesbian, Gay, Bisexual & Transgender (LGBT) Victims- Broken Rainbow: 0300 999 5428 or 0845 260 4460 • Support for Male Victims. Respect: 0808 801 0327 • Help for the Perpetrator. Respect: 0808 802 4040 • Childline: 0800 1111 • Debt helpline: 0808 808 4000 • Family lives (formerly Parentline): 0808 800 2222 • Citizen Advice Bureau: 0344 411 1444

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© Marie Chellingsworth (2020). The CBT Resource.

Your notes

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© Marie Chellingsworth (2020). The CBT Resource.

Your notes

© Marie Chellingsworth (2020). The CBT Resource.

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Marie Chellingsworth The CBT Resource ® Marie is a renowned consultant, academic and author in CBT. She is the Founder of The CBT Resource and Subject Matter Expert for a number of CBT and digital mental health services. Her work via The CBT Resource aims to help more people with anxiety and depression to be able to access evidence based treatments. She has over twenty years experience, publishing a wide range of CBT self help packages and national training for practitioners supporting people with these difficulties. She has worked with UK national bodies to maintain standards for CBT based approaches and was Consultant to the Australian Improving Access to Psychological Therapies programme. Prior to developing The CBT Resource, she was the Executive Director of Evidence Based Programmes at UEA, Senior Lecturer and Course Director at the University of Nottingham. Her passion for CBT and mental health first came after hearing a song called Howard Hughes (a B side of a band called Ride in 1992!). Outside of work she loves music, renovating her home and also spending time on local beaches and in the countryside with her Irish Setters. www.thecbtresource.co.uk

Andy Poplar [Vinegar & Brown Paper]® The photographs of etched glass throughout this programme are the work of Andy Poplar from [vinegar & brown paper]® ideas etched in glass. Special thanks and credit goes to him for enabling us to use these images. An award winning advertising creative, he set out to mend his head with [Vinegar & Brown paper] after his own experience with anxiety and depression.

At the heart of Andy’s work are his reflections upon his own experiences that led to his career change into etching glass. As [vinegar & brown paper], Andy has spent the last 8 years taking vintage or iconic items of glassware and bringing them to life with the tools of typography, wit, word-play and a slightly askew way of looking at the world. You can now find pieces of [vinegar & brown paper] on bookshelves everywhere, from York to New York (and a much happier man too).

You can find more of Andy’s work on his website and his Facebook and Instagram pages on the links below.

Website: www.vinegarandbrownpaper.co.uk Instagram: instagram.com/mendyourhead Facebook: facebook.com/mendyourhead

© Marie Chellingsworth (2020). The CBT Resource.

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