What is Behavioural Activation?
Behavioural activation (BA) is a psychological treatment (or treatment component) which aims to help people understand the positive impact of particular activities on their mood, and to increase the frequency with which they engage in these activities. BA also ensures that these activities are valued, rewarding, and are completed even in the face of barriers – as therefore the protocol includes psycho-education, activity monitoring, values assessment, contingency management and problem solving skills.
When was it developed?
BA was originally developed by Peter Lewinsohn in the 1970’s, who theorized that low mood in people was at least partially caused by these individuals obtaining a lower level of positive reinforcement in their daily lives compared to other people – and that this was a result of them a) less frequently engaging in pleasant or accomplishment orientated activities and b) finding these activities less inherently rewarding.
What is the research behind the theory?
Some research supports this theory. For instance, community based studies find that depressed adults do fewer activities than adults who are not depressed, and that they also find them less rewarding. Studies have also found that children and adolescents who do less extra-curricular activities (eg sport, music and other activities) are more likely to have mental health difficulties than other children.
Research and writing on models about psychological health more broadly also fit with behavioural activation. For example, self determination theory and supporting research states that people need autonomy, social connection and a sense of competence in order to have positive mental health and without these factors, they are more likely to experience poor mental health. This research fits with the behavioural activation framework which attempts to increase activities linked to all three of these components.
Is BA an effective psychological therapy?
There have been many studies examining behavioural activation for depression in adults compared to TAU or wait list controls, and they usually find large positive effect sizes.
Studies comparing BA to CBT for depression in adults usually find BA is equally effective as a fuller CBT program. (Of course, it’s worth noting that every “bona fide” treatment for depression works about equally well, so the BA/CBT equivalency is probably about larger issues than just demonstrating the effectiveness of BA).
BA has also been shown to be effective for grief, promising for some anxiety disorders and a meta analysis also found it is often effective for PTSD too.
Theoretically, given that BA is a comparatively simple concept, and potentially easily understood by young people, it might be expected to be effective for this demographic too. Unfortunately (as usual), there is significantly less research examining the effectiveness of BA in kids compared to adults, however there have been a handful of good studies – and a meta analysis in 2019 of 19 of these studies found BA to be associated with large effect sizes for depressed adolescents. A few of these studies included pre-teen children as well.
Adding to the weight of research concluding BA is helpful is the fact that “BA-like” components are found in most evidence based manualized CBT protocols.
Finally, there are some trans-diagnostic protocols for adults and children which include BA (eg “Exposure and BA”) which have been found to be effective for a range of mental health conditions.
Do we know anything about why exactly BA works – and therefore what we might emphasise in treatment?
There have been some component and mediation analyses of BA treatments – but not many – and all done with adults.
For example, one study concluded that in session practice of problem solving potential barriers to doing activities was linked to better learning of problem solving skills outside sessions than BA protocols which didn’t have any component of practice. In a similar vein, other studies have suggested in session concrete goal setting was linked to better outcomes.
One review of a mediator analysis suggested it wasn’t actually the increase in activities itself which led to more mood improvement – but possibly an increase in environmental rewards associated with the increased activation (ie the more pleasant feelings experienced after the activities). One author of a mediation analysis suggested it could also be the increase in social skills and social contact which was the most important component.
Another study found that clients who had a therapist who more thoroughly implemented a BA treatment improved more at a follow up than therapists who did more “improvisation”, and also found the clients who had the greatest increase in their coping abilities and who credited themselves the most for “self improvement” also improved more at follow up – and this was more closely linked to improvements in mood than the number of activities themselves. Perhaps BA is useful because clients start believing they are doing well.
Unfortunately overall we don’t have enough evidence to tell us whether any of the above are the critical ingredients but depending on the client, it may be worth emphasizing these as they are likely to be helpful.
When/How to use BA with children and adolescents
BA is worth considering when working with children who are experiencing low mood – including irritability and sadness (potentially in the aftermath of challenging life experiences, or in the context of depression, or when trying to manage anxiety disorders or other mental health /neurodevelopmental differences).
I am also likely to consider BA when I work with children who might not necessarily meet criteria for mood disorders, but are spending lots of time ruminating on negative life events/self appraisals, or who appear to generally have low levels of autonomy, social connection and meaningful activity. This includes young people who spend lots of time on activities which appear to be having negative effects on mood (eg spending lots of time on YouTube/social media in an attempt to *improve* or cope with their negative mood, which paradoxically is actually decreasing it).
How to implement a BA intervention in kids:
Here are some of the steps we might take to implement a BA intervention (entire protocol or component) for kids.
Psychoeducation
- Provide psychoeducation about the ’withdrawal – low mood/irritability‘ loop.
This means we explain to young people that the less activities we do, the more likely it is we miss out on rewarding feelings and experiences, and that this might lead to a “deactivation” (depending on age/developmental stage of the child) of brain regions which produce good feelings.
I like to use a visual diagram which outlines this circular loop: withdrawal of (personalise the activity for the child) – arrow – low mood/low brain activation – arrow – withdrawal).
Instead of a loop, we can also use a “spiral” diagram which outlines several loops underneath each other: withdrawal from activity 1 (personalise) – arrow downwards – low mood/low brain activation – arrow downwards – withdrawal from activity 2 (personalise) – arrow downwards – leads to even lower mood/lower brain activation etc.
- Provide psychoeducation about the ‘activity – better mood’ loop.
It is also important to provide psychoeducation about the opposite concept – ie that doing more activities may lead to more rewarding feelings.
As this is simultaneously both a very simple concept and also one that is very hard (requires young people ignoring their instinctive desire to withdraw/avoid) – it can be helpful for some young people discuss this concept in more detail and take some time over.
This might mean talking about neurological concepts related to activation of brain centres and systems associated with positive mood. It might also mean drawing the logical consequences of a long term pattern of activation behaviours and what this might specifically mean for a child and why this might be beneficial.
As always when working with young people, having a visual representation of ideas is helpful – the same visual (loop or spiral) diagrams described above, but in the positive direction, can also be used.
- Provide psycho-education about the types of activities which are more likely than others to lead to improved mood.
Coming up with meaningful, value based activities is not easy for children with emotional health difficulties. This can be made easier by presenting them with categories of activities.
I use four of these categories which are as follows: ’being with people activities‘ (conversations with others, time spent with friends online or offline, time with family or extended family – or anything in the company of other people), ’ticking stuff off /goal activities‘ (projects related to school, hobbies, investigations, practicing sporting or musical skills – or other skills, making something, rehearsing, collating information, working towards career goals etc), ’fun activities‘ (anything a child finds fun – games, reading, online gaming, watching videos), and ’helping activities‘ (volunteering, caring for a pet, caring for family members, checking in or being kind to friends, being an activist, gardening, caring for the environment).
As always when working with children, we should consider having parents/caregivers in the room (dependent on the age of the child and funding body) either at the end of the session or during the entirety of the session. This means we can provide the same psycho-education to parents/caregivers so they can reinforce the concept outside of sessions. If parents/caregivers are only attending at the end, one option is to ask the YP to explain to their parent/caregiver the ideas covered while they were out of the room – this can assist in knowing whether they have understood it themselves.
Activity monitoring.
This step involves young people monitoring and noticing their mood and how it is linked to activities. We can send home a calendar style worksheet in which young people and their families list the general categories of activities they did across each day (ie morning, afternoon, evening) and the mood they experienced (out of 10, or using emoticons) while they did this. This can then be used to identify patterns.
Depending on the time/client, I might replace this ’at home‘ activity monitoring with a verbal examination of this concept in session. This might mean asking the child to generate the general categories of activities they do during the week, writing these down with them – and then simply asking them to rate their belief about their mood next to each one. However, even if I just do this as an in session activity, I might still ask the child to take it home and used as a “right/wrong” experiment activity in which the child checks it for how accurately they predicted their mood during these activities.
Identifying activities which fit with values and goals
In order to find activities for the young people which are more likely to improve their mood, we need to help them identify the values and tasks which matter most to them.
Ways to do this might include the following:
- Using preprinted value card decks (available online) which include potential values or desired personal attributes and asking children to choose which they most highly value
- There are online questionnaires which children can complete (google “value identification questionnaires – children” or “personal strengths questionnaires – children”).
- Use the following questions (with appropriate imagery/visual props – eg magic wand/drawing on a whiteboard): Imagine you are (pick an age – often it might just be a year or two older than the child currently is). What would you be doing, thinking about and spending time on if you had the “best life” you can imagine at that age? Using domain specific prompts (eg friends, family, interests, academics, sport, spiritual, health etc) – ask follow up questions to create a detailed ’map‘ of values and goals in various areas. We can then ask kids about what small activities or small steps towards activities they might need to be actually doing in order to achieve the goals and values identified above.
- Ask young people and families to find extra-curricular, social, achievement orientated and helping activity options – by contacting their school, looking at noticeboards/social media in local areas/local councils, at church organisations, not for profit groups etc – and then ask children to think about which activities would be most interesting for them.
I should pause at this point and acknowledge finding (affordable and convenient) activities for children – especially those with mental health challenges – is not easy. (Dare I say it, but sometimes I even wonder if Australia had a few less mental health services and a few more easily accessible, free and convenient options for increasing social, achievement orientated, helping and fun activities for young people – whether the mental health of our young people would improve.) At any rate, even if we have managed to find a range of options for young people – some of the time, young people’s mental health challenges mean they still lack any interest in any activities at all.
If this is the case (providing we are sure we have thoroughly redone a psycho-education and motivational interviewing process) we might need to work with parents/caregivers to help them make a decision about how much to ‘push‘ or insist upon some activities being part of their life (including perhaps using consequences for involvement/non involvement), and/or how much to just allow the child to determine how much and what they will do themselves (we will encourage but allow you to make your own decisions about what you want to be involved in).
There is no easy way for parents/caregivers to determine how much to ’take charge‘ here or ’let go‘. It will depend on a variety of factors such as the following:
Age – it is sometimes easier for parents/caregivers to insist younger children are involved in activities compared to older children. For this reason, I often tell parents of younger children to consider making a family rule about involvement of activities when they are young, knowing how important it will be for mental health when they are older – and that it might become harder as they get older.
Relationship – parents/caregivers who have a closer relationship with children are sometimes able to ’push‘ a child more – because their relationship is strong enough to withstand the challenge which comes with insisting a child be involved in more activities.
Temperament – some young people with mental health challenges also have a very strongly independent temperament, and trying to talk about this and support young people to do this backfires and is not the right approach.
Extent of mental health challenges and potential benefits – some children have serious mental health challenges and are in desperate need of more activities in their life, and therefore their parents/caregivers are prepared to do more work/put consequences in place in order to ensure this occurs. Other children may have lower mental health needs and/or extra activities in their life may not be as beneficial or needed – in which case it might not be worth parents/caregivers insisting these occur.
Parent time/energy resources – supporting children with mental health challenges to have more social, physical, helping and goal orientated activities in their life can be a very time consuming, tiring and never-ending task. Sometimes parents/caregivers can scrape together the energy to be working on this (usually slowly) but sometimes understandably they just don’t have the energy to do so.
Setting up a schedule for activities
Once we have assisted young people to identify activities they have some interest/willingness to be involved in, we need to assist them to decide when, how much and for how long these fit into their life. Given the research listed earlier, it is likely that the more specifically we can set up schedules for young people in session, the more likely it is that BA effectively increases mood. This usually means some kind of rehearsal or planning activity in sessions (ie not just “talking” about the idea).
In session activity/rehearsal of this concept might mean:
- Getting out phone/device calendars to set up times/appointments
- Drawing up a pen and paper schedule to take home
- Setting alarms in session for activities
- Bringing in/calling others (parents/caregivers/teachers/siblings/family) to support and provide accountability to the schedule
- Identifying specific numbers of times the activities will occur over a certain time period and for specific lengths of time (some research suggests identifying a ’range‘ is more likely to be complied with than identifying a specific numerical target)
- Identifying the specific places and times the activities will occur
When setting up schedules, week to week is often best to set up for short period of time – ie 2 weeks – as a trial, rather than for the long term. This can be explained as an ’experiment‘ to see how it impacts on mood.
Contingency Management
In this step in BA, the therapist helps the person to increase the likelihood that doing their planned activities will be associated with positive rewards, and to attempt to remove any rewards a child experiences from withdrawing from/avoiding planned activities.
Research suggests that BA is effective not just due to the completion of the activities but due to the potential ’rewards‘ (internal) the YP experiences from doing the activities, so it is important to build in some way of the activities leading to positive results as much as possible.
Strategies to do this might include:
- Noting down the activities and mood after these activities
- Having the child tell someone else about how well they did after they complete the activity
- Creating some kind of ’ticking off‘ visual record to notice progress
- Encouraging the child to congratulate themselves after doing the activity
- As therapists providing positive reinforcement in sessions about the child’s completion of activities and linking this to personal satisfaction (ie noting increased ability to do activities even when don’t feel like it)
- Liaising with children/families so that they commit to ensuring ’easier‘ activities which might typically take the place of the planned activities and act as positive reinforcement – are not as easy to do – for example, if the child doesn’t do the activity as planned, they are not as easily – or as quickly – able to access Wi-Fi/devices
Problem Solving and Rehearsal
Building problem solving skills is an important part of most BA treatment protocols – in this step the therapist helps the person identify the barriers (ideally in advance) to following the activity schedule and problem solving to ensure the activities occur.
In my experience it is really important to do this with kids also.
We can be up front about the gap between ’talking and planning‘ and ’doing and following through‘. We might say things like:
- This is all good in theory, but tell me – really – what is going to make this hard to actually do when it comes to the day?
- How much on a scale of 1-10 do you think you can follow through and do these things? What would make it a X(less than 10) rather than a 10?
- What could you do when you really don’t feel like it?
- Do you really believe these activities will actually help you – or not really?
As well as having a conversation about problem solving, we can also use rehearsal components in session.
For example, the child and therapist might role play being the ’Cant’ be Bothered Brain‘ and the ’I am going to do this Brain‘ and talk with each other about how the ’I am going to do this‘ brain wins against the ’I can’t be bothered brain’.
We might also make phone calls/liaise with schools/parents/caregivers within session to overcome problems or barriers.
We might make a ’solving problems tool kit‘ that we make which consists of activities to do when stuck (eg make it smaller, ask for help, get ready before hand (simple option for creating this tool kit _cut up strips of paper and staple the ends together).
Again, involving parents/caregivers in problem solving is also often very helpful. They can provide insight into problems and practical solutions. They can also, depending on the YP, agree to help keep children accountable. As always, this will depend on the child’s age, situation and temperament.
Follow up and monitoring
BA involves active follow up and monitoring after initial activity planning and scheduling occurs. This kind of appropriate and active follow up might include the following:
- Ensuring follow up sessions happen at an appropriate time (ie weekly sessions rather than monthly)
- Involving parents/caregivers in sessions rather than just children
- Empathic and frank discussion with families which includes:
- Specific and detailed questioning about which of the planned activities did occur
- Praise, encouragement and authentic thanking of young people for engaging in the activities which did occur
- Calm and honest discussion of activities which did not occur – this might include:
- What were the barriers which prevented them from occurring
- Their (child and families) level of belief in the importance of these activities
- Rediscussing the rationale (and possibly the explanation of research evidence) for the usefulness of the planned activities/BA approach
- Calm resetting of goals as appropriate – and repeating the steps above about time limited, specific in session planning, rehearsal and problem solving.
This follow up takes courage on behalf of the therapist at times, as children and their parents will sometimes feel like it is ‘too hard’ and be wanting alternative options for management of mood without having implemented BA thoroughly. If we truly believe the BA approach to be useful, it is important to be honest and courageous – kindly and compassionately – in this work and these conversations, and to attempt to implement the BA approach with fidelity, rather than just rushing on to using another approach.
All the best in using BA for the kids you work with.
