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Section 4
Behavioral Activation as A Common Mechanism

Question 4 | Test | Table of Contents

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In the last section, we discussed Behavioral Activation Therapy.  Three steps to Behavioral Activation Therapy with a bipolar client are identifying moments of inaction, emphasizing behavior’s contribution to mood, and emphasizing routine. 

In this section, we will continue to discuss Behavioral Activation Therapy with a bipolar client.  The focus in this section, however, will be on cognitive behavior therapeutic strategies following the initial assessment.  When implementing Behavioral Activation Therapy, three basic steps can be followed.  These are identifying alternative actions, identifying and engaging previously rewarding activities, and fostering the cognition of devaluing thoughts as distractions.

CBT: 3 Step to Implement Behavioral Activation Therapy

♦ #1  Identifying Alternative Actions
First, let’s discuss identifying alternative actions.  After Betsy logged her activities and associated moods for one week, she was asked to identify alternative actions that she perceived as fulfilling.  I stated to Betsy, "These should be short-term activities that you believe will yield a more positive emotional reaction.  What activities do you see as sufficiently rewarding and feasible?"  Betsy stated, "Whenever I clean the kitchen and do all the dishes, I always feel so much better." 

Like Betsy, your client’s activities may require little time, but is often part of a larger or more long term goal he or she may or may not have yet defined.  Through these smaller activities which lead to the accomplishment of  larger goals, clients are supported in gradually developing an expanded set of behaviors that, through their engagement help to ‘pull’ them through the depressive states associated with bipolar disorder. 

Bernard Golden offers an example of this approach in his work with Yvonne, a 32 year old bipolar woman who started treatment shortly after hospitalization for depression.  Yvonne was on a leave of absence from her job, and while she hoped to return, at that time she barely had sufficient energy to manage the upkeep of her apartment. 

As part of her treatment plan, Yvonne was asked to identify how she felt upon waking in the morning.  Yvonne described terrible fatigue attributed in part to the effects of new medication.  Yvonne stated, "Even thinking about organizing my apartment seems too much because of the energy it would take." 

Yvonne was asked to start small and identify several activities that she could engage in during the first few minutes after awakening that would be rewarding for her.  She was encouraged to imagine these activities rather than the initial moment of engagement.  In this way, she could come more fully in touch with a mood of increased satisfaction and reward even before beginning the activity.  As you are aware, the emphasis was on helping Yvonne overcome inertia rather than focusing on the long term goal of returning to work. 

Yvonne identified several activities that included clearing the top of the bathroom vanity, organizing one area of her kitchen counter, hanging up some of her clothes, and spending ten minutes cleaning the refrigerator of unedible food.  Yvonne began to learn that these activities were a series of individual tasks, serving a distinct reward and contributing to a larger goal. 

♦ #2  Identify and Engage Previously Rewarding Activities
Next, let’s discuss identifying and engaging previously rewarding activities.  Yvonne reported that walks, sketching, and talking to friends were activities which were rewarding prior to the onset of her depressive states.  Clearly, the goal of this aspect of treatment was to help her continually identify and engage in activities as a way of overcoming inertia. 

♦ #3  Foster the Cognition of Devaluing Thoughts as Distractions
In addition to identifying alternative actions and identifying and engaging previously rewarding activities, the third step in implementing Behavioral Activation Therapy is to foster the cognition of devaluing thoughts as distractions. According to this model, even self-devaluing thoughts associated with depressive states and bipolar disorder are viewed as distractions from facing the discomfort of a particular action. 

As such, the behavioral activation therapist can help clients recognize such thoughts as distractions rather than addressing and challenging them for the content they convey.  They’re taught to increase their awareness of how time spent engaging in such thoughts further fuels depression.  Clients like Yvonne of Betsy are also encouraged to observe their thoughts without judging them, which helps them to avoid getting stuck trying to eliminate them. 

Think of  your client.  Do you think that Behavioral Activation Therapy might help your client in managing the depression associated with bipolar disorder?

Peer-Reviewed Journal Article Reference:
Boswell, J. F., Iles, B. R., Gallagher, M. W., & Farchione, T. J. (2017). Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders. Psychotherapy, 54(3), 231–236.

Eyal, T., Steffel, M., & Epley, N. (2018). Perspective mistaking: Accurately understanding the mind of another requires getting perspective, not taking perspective. Journal of Personality and Social Psychology, 114(4), 547–571.

Dimaggio, G., & Shahar, G. (2017). Behavioral activation as a common mechanism of change across different orientations and disorders. Psychotherapy, 54(3), 221–224.

Gilkes, M., Perich, T., & Meade, T. (2019). Predictors of self-stigma in bipolar disorder: Depression, mania, and perceived cognitive function. Stigma and Health, 4(3), 330–336. 

Goldberg, S. G. (2019). Narratives of bipolar disorder: Tensions in definitional thresholds. The Humanistic Psychologist, 47(4), 359–380. 

QUESTION 4
What are three steps regarding implementing Behavioral Activation Therapy? To select and enter your answer go to Test.

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