Behavioral Activation (BA) Program

Treatment Manual

C. W. Lejuez1 & Derek R. Hopko2

University of Maryland, College Park1
University of Tennessee, Knoxville 2

Address Correspondence to:

C.W. Lejuez, Ph.D.

University of Maryland
Department of Psychology
College Park, Maryland 20742
clejuez@psyc.umd.edu
 Session 1

Session One Key Elements:

1. Introduction

2. Discussion of Depression

3. Introduction to Treatment Rationale

 What about trauma and loss in your life?

 Why is coming every week important?

4. Introduce Daily Monitoring (Form 1)

 Importance and Enjoyment Ratings

5. Important Points about the Structure of This Treatment

Introduction

We will begin with a discussion of how you are doing and why you have come to therapy.

It is important to have an opportunity to talk about your experience, thoughts, and feelings. Let’s

spend some time hearing about what has brought you here today.

Based on your initial intake interview, it sounds like you are experiencing symptoms of

depression. I would like to begin by discussing depression and how it can affect your life.

Discussion of Depression

Depression is defined as an extended period of time (at least two weeks) in which a person

experiences depressed mood or a loss of interest or pleasure in activities that were once enjoyed.

Many people will experience at least one episode of major depression in their lifetime. Although

depression most often occurs between the ages of 25 and 45, it can affect people of all ages,

cultures, income, education, and marital status.

For many people, the onset of depression clearly is related to stressful life events including

a traumatic experience, loss of a loved one, financial difficulty, or job loss. For others, the specific

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causes of depression may be unclear, and it might start without warning. Whether it lasts a couple

of weeks or as long as several years, depression may produce significant difficulties in life

functioning (for example, an inability to work or take care of one’s children). Resulting problems

may include decreased optimism/motivation, low self-esteem, trouble concentrating (paying

attention), self-harm, and/or suicidal thoughts and behavior. Medical problems resulting from

depression can include heart disease, chronic pain, drug abuse or dependence, fatigue, and

malnutrition. Individuals with depression may isolate from others and/or withdraw from activities

in life that may result in loneliness, relationship problems, decreased job satisfaction or

unemployment, and educational failure. Given these resulting problems, the identification and

treatment of depression is critical.

Depression can range from very minimal depressive symptoms to severe clinical

depression. Some people have proposed that the development of depression symptoms is related

to many factors that include behavior, the environment, cognitive (including thoughts, beliefs, and

feelings), biological, and social influences. These factors may act independently or together to

produce and maintain depressive symptoms. If depressive symptoms are severe, major depression

may be diagnosed. Symptoms of depression may include:

 Feeling sad or down most of the time

 Loss of interest in usual activities

 Significant weight loss or weight gain

 A decrease or increase in appetite

 Difficulty sleeping or sleeping too much

 Feelings of agitation or irritability

 Feeling tired or loss of energy

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  Feelings of worthlessness or excessive / inappropriate guilt

 Difficulty thinking or concentrating or making decisions

 Crying spells

 Feeling hopeless

 Thoughts about killing yourself or attempting to do so

Although most individuals experience some form of many of the above symptoms, these

symptoms must either result in significant feelings of distress, or interfere with day-to-day

functioning for a diagnosis of depression to be made.

Introduction to Treatment Rationale for Behavioral Activation

Behavioral activation (BA) is based on the idea that the best way to reduce your

symptoms of depression is to become aware of the a) life areas that are most important to you, 2)

the values you have in those life areas, 3) what activities you can do to live according to your

values. For example, important life areas may include 1) your relationships, 2) your job, or 2)

sports and recreation activities. Values in those life areas might be 1) showing love to someone

you care about, 2) completing work duties with pride, and 3) become physically healthy. Once

you have identified those life areas and values, we will use these life areas and values to identify

and perform daily activities. This is important because when you become more active you are

more likely to experience positive and enjoyable situations. It is difficult to feel depressed or and

have low self-esteem if you are regularly doing activities that bring you a sense of pleasure and/or

accomplishment.

This manual targets changing your behavior and your surroundings as a method for

improving your thoughts, feelings, and overall quality of life. Many individuals with depression

often feel tired and lack the motivation to do various activities and think that once they have more

energy and think more positively, they will be able to do activities they have ignored or have been

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unable to accomplish. The opposite approach is taken in this treatment – behavior is changed first,

which leads to increases in energy, motivation, and positive thinking and feelings. The focus on

behavior change, however, does not mean we ignore thoughts and feelings. Instead, we suggest

that negative thoughts and feelings will change only after you change your behavior and are

experiencing positive events more frequently. Healthy behavior is defined as behavior that is

directed toward improving your quality of life, and is directed toward the attainment of the values

and goals you have in your life. In contrast with healthy behavior, unhealthy behavior generally is

not directly related to improvements in the quality of your life and does not move you closer to

accomplishing your goals or values.

Be aware that it is possible for you to be engaged in many activities, yet still depressed.

This can happen if you feel overwhelmed with activities that are unfulfilling and that limit your

ability to live according to your values. For example, although you may be active at work and

home, these activities may be focused only on helping others. Although it certainly is important to

help others, it is never a good idea to focus so much on others that your needs and feelings are

totally neglected. This exclusive focus on the needs of others may result in feelings of emptiness

and dissatisfaction, followed by confusion and guilt for having such feelings. Thus, it is not only

important to engage in many activities, but at least some of these activities must bring some

degree of pleasure and fulfillment.

What about trauma and loss in your life? Often people who have experienced a traumatic

event in their life end up having long standing feelings of depression. After something terrible has

happened or loved ones are lost, life feels empty, and not worth living at all. It can feel that there

is very little to live for and that all the support and happiness you once had is gone forever.

Thoughts and bad dreams may keep coming back about the bad experience or about the loved one

who has passed away. In BA, it is very important that the counselor understands what happened

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to you, how you felt about it, and most importantly, how this affects your life now. At every

session, as the BA counselor, I will ask you to spend some time talking about events in your life

that have led to your depression. However, this treatment requires more than just talking about

what has happened. In addition, I will also ask you to spend some time trying some strategies that

will help you to live a more fulfilling and meaningful life. Although nobody can change events of

the past, we can plan for a better future by what we do today. Often when people have

experienced traumatic events and loss, negative thoughts and feelings about the event come to

mind all the time. It becomes hard not to think about it or feel terrible that it happened. In BA, we

find that it is important to understand how these experiences are impacting your current behavior.

For example, you might find it difficult to sleep at night, and so you spend a lot of time sleeping

during the day. If you sleep during the day, you may be unable to perform important daily

activities or lack the energy and desire to socialize with family and friends. BA is an approach that

will help you identify activities that might be making your depression worse and helping to change

those activities so that you feel depressed less often. The goal of BA is to help you make the best

life possible for yourself, starting with today. This can be hard work, but if you trust in the process

you will find that good things will come from your effort. We will work at a pace that is

comfortable for you. Are you willing to work on this together over the course of treatme nt?

Why is coming every week important? Depression is a problem that builds over time, and

so it is not possible for it to be treated in a few days or after just one or two visits. It takes some

work and it is very important to practice all of the strategies of BA with the help of your

counselor. After about 12 weeks most people feel they have practiced the strategies enough to

where they can begin to rely more on themselves and need therapy less. For this reason, only

coming to a small number of sessions may not be helpful. Consider the example of cancer

treatment. It is very important that you attend regular chemotherapy sessions to completely

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eliminate the cancer. It would not be helpful to come to only half of your chemotherapy sessions

or just one or two- even if you begin to feel better. It would also not be helpful to skip several

weeks between chemotherapy sessions. The cancer will continue to grow in between sessions,

only worsening. Although it might seem very different, the treatment of depression requires the

same structure and consistent attention. For this reason, we ask that you commit to giving this

your best try by coming to all the sessions. We realize sometimes unforeseen events can arise that

might cause you to miss a session, and this is understandable, but we urge you to not miss

sessions because you are feeling depressed, tired, or unmotivated. We can talk about those

feelings and most people will find that even when they are feeling this way, they feel much better

after they have come to session and begun to work on a plan to overcome their depression. As

your counselor, I am committed to work with you and will do my best to help you feel better, and

I just ask that you are also committed to doing so as well. Based on the example above, we also

urge you not to stop coming to treatment until it is over, even if you are feeling better and even if

you are feeling worse.

Introduce Daily Monitoring (Form 1)

Because the main focus of this treatment is increasing your level of healthy behavior, it is

important to get an accurate assessment of your daily activities. Although you may believe that

you know how you are spending your time, we would like you to spend one week recording your

activities. This is useful for several reasons. First, it provides us a measure of your activity level

right now that we can compare to your activity level later in treatment after you use the treatment

strategies. Second, an examination of your current level of activity may help you to realize that

you are less active than you originally thought or that you are spending large amounts of time

engaging in behavior that is contributing to your depression. Seeing this may motivate you to

increase your healthy activity level. Finally, a close examination of your daily routine might lead

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you to develop some ideas about what activities you have time for and might enjoy. To monitor

your current activities, we ask that you keep a detailed record (hour by hour) of all activities that

you do, including those that seem insignificant such as sleeping or watching television. You will

use the Daily Monitoring Form 1 to record your activities. You will need to complete one form

for each day. For the next week behave in as “typical” a manner as possible. Your only task is to

write down your activities, trying to be as accurate and as thorough as you can.

Importance and Enjoyment Ratings. Once you have recorded the activity, we ask that you

then rate the activity in terms of two things: Importance and Enjoyment. For the Importance

rating, think about how important in your heart it is to have this activity in your life. On a scale

from 1 to 5, with 1 meaning that the activity has no importance at all and 5 meaning that the

activity is of the highest importance in your life, rate each activity. For example, going to work is

probably a very important activity in your life because it is your source of income to support your

family. You might give your work a rating of 5. On the other hand, watching television is probably

a less important activity in your life. You might give watching TV a rating of 1. For the

Enjoyment rating, think about how much you enjoy the activity, in other words, how much fun

you are having when you are doing the activity. You will use a 1 to 5 scale for Enjoyment as

well. A rating of 1 will be for activities that you do not enjoy at all. A rating of 5 will be for

activities that you enjoy very much. For example, going to a picnic might be considered a very

enjoyable activity and be assigned a rating of 5, while washing the dishes might be considered no

fun at all and be assigned a rating of 1.

Consider for a moment that some activities might be very important but not very

enjoyable, and other activities might be very enjoyable but not very important. For instance,

washing clothes might be high in importance but not very enjoyable, whereas watching a favorite

TV program might be a very enjoyable activity but not a very important activity. Meanwhile some

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activities may be rated as high on both importance and enjoyment and others as low in importance

and enjoyment. For example, eating dinner with family might get rated as a 5 in importance and

enjoyment because both are very important and very enjoyable. On the other hand, lying in bed in

the afternoon might be rated a 1 in both importance and enjoyment because it is neither important

to your life nor very enjoyable.

To complete Daily Monitoring, you might choose to record your activities as you go

through your day or you might prefer to wait until the end of the day and then record all the

activities of the day all at once. You may do whichever is your preference. However, it is best to

record your activities of the day on the day of the activities, as opposed to several days later. For

example, it will be difficult on Friday to remember the activities from Monday. We will review

your Daily Monitoring Forms each week so be sure to bring the completed forms to your session

next week.

Important Points about the Structure of This Treatment

Before we finish today, it is important to understand that BA is a structured treatment.

This means that treatment involves a series of steps over the course of treatment. It is very

important for you to come every week, because each session builds on progress from the previous

session. Further, you should know that these sessions will include assignments for you to work on

in the session and then assignments for you to work on at home. It is important for you to commit

to coming to each session and doing your best on the assignments at home so that you will see

real improvements in your life.

Assignments:

1. Complete Daily Monitoring (Form 1).

Session Two

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Session Two Key Elements:

1. Review Daily Monitoring (Form 1)

2. Introduce and Complete Contracts Part 1: Identifying Supportive People (Form 2:

Top Part)

Review Daily Monitoring (Form 1)

We will begin this session by reviewing your Daily Monitoring Forms (Form 1) from the

past week. It is important to notice the types of activities you are doing and if they are enjoyable,

important, both, or neither. Often people with depression find themselves spending very little time

in activities that are enjoyable. They often also withdraw from activities that are important to

them. It is useful to take some time to discuss your level of activity and how often you are doing

enjoyable and important activities. In the next few sessions, we will focus on making changes in

your daily activities, but right now do not try to change anything. Instead, just pay attention to

what your life is like everyday, what you are doing, and to what extent these activities are leading

you to feel better or worse.

Introduce and Complete Contracts Part 1: Identifying Supportive People (Form 2: Top Part)

Although being motivated is very important, your chances of overcoming depression are

improved when you have support for your healthy behavior. To begin, you should talk with your

family and friends about your need to gradually increase your level of healthy behavior.

Sometimes family and friends are more likely to notice your depressed behavior than your

attempts at healthy behavior. Ask them to help you with this by helping you decrease your

depressive behaviors (including talking about depression), and focus more on your efforts towards

more healthy alternatives. Of course, we all need support and someone to listen when life is not

going well, but the goal is to keep your depression from being the focus of your interactions with

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others. Further, ask them to help you be more active, and also to not do things for you when you

are depressed. You want them to help you be independent, not to take care of all you

responsibilities so you are dependent on them. Once we work to develop a list of healthy

activities, we will help you make Contracts with friends and supportive family members to help

you accomplish these activities. You will not have to do too much with Contracts right now. In

fact, right now you only have to think about the people in your life, friends or family, who support

you in some way. Using the Contracts (Form 2), you will begin by listing each person on the top

part of the form. Later in Session 7, and throughout the rest of treatment, we will work together

to complete the bottom part of the form for each person to help you seek support for the life

changes you are trying to make.

Assignments:

1. Complete Daily Monitoring (Form 1)

2. Add Contracts Part 1: Identifying Supportive People (Form 2: Top Part)

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 Session Three

Session Three Key Elements:

1. Review Daily Monitoring (Form 1)

2. Review Contracts Part 1: Identifying Supportive People (Form 2: Top Part)

3. Introduce and Complete Life Areas and Values (Form 3)

Review Daily Monitoring (Form 1)

We will begin this session by reviewing your Daily Monitoring Forms (Form 1) from the

past week. It is important to notice the types of activities you are doing and if they are enjoyable,

important, both or neither. Often people with depression find themselves spending very little time

in activities that are enjoyable. They often also withdraw from activities that are important to

them. It is useful to take some time to discuss your level of activity and how often you are doing

enjoyable and important activities. In the next few sessions, we will focus on making changes in

your daily activities, but right now do not try to change anything. Instead, just pay attention to

what your life is like everyday, what you are doing, and to what extent these activities are leading

you to feel better or worse. You might also find that over time, recording your activities in this

way becomes easier.

Review Contracts Part 1: Identifying Supportive People (Form 2: Top Part)

If you were able to identify other supportive people to list in your Contracts over the past

week, be sure to write each persons name down on separate Contracts (top part of Form 2).

Introduce and Complete Life Areas and Values (Form 3)

An important step in BA involves determining the activities you would like to add to your

life. The activities that you select should be ones that are important and/or enjoyable to you. One

way to help identify activities is to think about what you value in life. Think for a moment about

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each of the following areas of your life. What are your values in each of these areas? A value is

something that is important to you in your heart about that life area. Think about each of the

questions below.

1. Family Relationships: What type of brother/ sister, son/ daughter, father/ mother do

you want to be? What qualities are important in your relationship with those in your

family? What is important to you about a good family?

2. Social Relationships: What would an ideal friendship be like to you? How could

your relationships with your friends be improved? What do you enjoy and cherish in

your friendships? How would new friendships enhance your life?

3. Romantic Relationships: What is important to you in your relationship/marriage?

What would you like your time with your partner to be like? If you do not have a

partner, would finding a partner enhance your life?

4. Education/ Training: Would you like to pursue further education, or receive

specialized training? What would you like to learn more about? What is important to

you about your education and training?

5. Employment/ Career: What type of work would you like to do? What kind of

worker would you like to be? What is important to you about your work?

6. Hobbies/ Recreation: Are there any special interests you would like to pursue, or

new activities you would like to do? What is important to you about your free time?

7. Volunteer Work/ Charity/ Political Activities: What contribution would you like to

make to the larger community?

8. Physical and Psychological Health Issues: What is important to you about your

general health, diet, sleep, exercise, etc.? What are your goals for this mental health

treatment? Are there other issues besides depression that you would like to address?

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 9. Spirituality: What, if anything, does spirituality mean to you? Are you satisfied with

this area of your life?

10. Responsibilities: What new daily responsibilities would bring you a sense of

accomplishment?

From these life areas, a primary goal of this session is to identify key values form each of

these life areas. For example, at the end of the session, you may identify a value as “wanting to

become a better wife or husband.” At this point, it is not yet necessary to identify specific

activities that you will do to accomplish these goals; You will identify activities to help you

achieve this value in future sessions. For homework, complete values across as many life areas as

you would like and bring these to our next session.

Assignments:

1. Complete Daily Monitoring (Form 1)

2. Edit and Add Life Areas and Values (Form 3)

3. Continue Adding Contracts Part 1: Identifying Supportive People (Form 2: Top Part)

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 Session Four

Session Four Key Elements:

1. Review Daily Monitoring (Form 1)

2. Review and Edit Life Areas and Values (Form 3)

3. Introduce and Complete Life Activities Checklist (Form 4)

Review Daily Monitoring (Form 1)

We will begin this session by reviewing your Daily Monitoring Forms (Form 1) from the

past week. It is important to notice the types of activities you are doing and if they are enjoyable,

important, both or neither. It is useful to take some time to discuss your level of activity and how

often you are doing enjoyable and important activities. In the next few sessions, we will focus on

making changes in your daily activities, but right now do not try to change anything. Instead, keep

paying attention to what your life is like every day, what you are doing, and to what extent these

activities are leading you to feel better or worse. You might also find that over time, recording

your activities in this way becomes easier.

Review and Edit Life Areas and Values (Form 3)

Once you have determined the importance of various life areas and identified values that

you would like to work toward, you are ready to start identifying activities. In completing this

exercise with me, you likely will identify activities that for each Life Area and related values

established in Session Three. For example, the life area of education and the related value of

attending college might include specific actions such as enrolling in classes, purchasing textbooks,

and studying several hours per week. As another example, the life area of family relationships and

the value of developing a closer relationship with a particular family member may include specific

actions such as eating dinner together every Saturday, calling them twice a week, or offering

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assistance (for example, baby sitting). Although completing activities aimed at a specific life area

and value can be satisfying, it is important to select activities across a wide range of life areas that

include both social activities as well as life responsibilities. One can think of this as a mix of

“enjoyable” and “important” activities.

Introduce and Complete Life Activities Checklist (Form 4)

“Life is about the journey, not the destination.”

The Life Activities Checklist includes a list of activities that people are often interested in

as well as spaces for you to write in your own activity ideas. Put a check next to activities on the

list that you would be interested in adding to your list. In general, if you believe that completing a

particular activity would bring a sense of pleasure and/or accomplishment, then it probably would

be good to include it. When selecting activities it is important to remember that they must have

two specific characteristics; they should be both observable by others and measurable. Therefore,

a general goal like "thinking more positive" is not appropriate, but “eating dinner with my mother

twice a week” would be appropriate. This latter activity could be observable and measurable in

the sense that you could meet with her twice per week. Thus, if these two conditions are met, you

have identified an acceptable activity. Sometimes it is tempting to select very difficult activities for

which the benefits are very delayed or uncertain. For example, getting a college degree is a long-

term goal. To address this potential problem without limiting your ambition, select activities

across a range of difficulty, with only a few being more difficult long-term projects. To improve

the likelihood of initial success and to help your transition into the program, three of the activities

you choose should be activities you already are doing regularly but would like to increase in

frequency or duration (see your Daily Monitoring Forms for assistance). We will spend some time

now in Session 5 going through this list, but you should consider reviewing these activities and

generating new ones on your own as well.

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Assignments:

1. Complete Daily Monitoring (Form 1)

2. Review and Edit Life Activities Checklist (Form 4)

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 Session Five

Session Five Key Elements:

1. Review Daily Monitoring (Form 1)

2. Review Life Activities Checklist (Form 4)

3. Introduce and Complete Activity Selection and Ranking (Form 5)

4. Introduce and Complete Activity Hierarchy (Form 6)

Review Daily Monitoring (Form 1)

We will begin this session by reviewing your Daily Monitoring Forms (Form 1) from the

past week. It is important to notice the types of activities you are doing and if they are enjoyable,

important, both or neither. What changes if any have you noticed since the first week you started

monitoring?

Review Life Activities Checklist (Form 4)

Now we will review the Life Activities Checklist. The most important thing is that all of

the activities listed are observable and measurable. We should also be sure that each activity is

related to a value that you identified on the Life Values Form.

Introduce and Complete Activity Selection and Ranking (Form 5)

You have identified many activities for each life area and related value. Today, we will pick

15 of those activities that we will begin with. As you select an activity, add it to Form 5 (Activity

Selection and Ranking). Remember that the activities should be both observable and measurable

and that activities should be directly relevant to the Life Areas and Values Assessment you already

completed (Form 3). The more you can address these life goals (in Form 3) in your activities, the

more likely you will experience the activities as both pleasurable and meaningful.

Introduce and Complete Activity Hierarchy (Form 6)

Once you have your 15 activities listed on Form 5, rank order them from 1 (easiest to

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accomplish) to 15 (hardest to accomplish) in Form 6 in the Activity Hierarchy. One way to do this

is to first identify the easiest and assign it a 1, then identify the most difficult and assign it a 15.

From there, try to fill in the others. The idea is that you will start with the easiest activities and

gradually work toward more difficult activities.

Assignments:

1. Review Daily Monitoring (Form 1)

2. Review and Edit Activity Selection and Ranking (Form 5)

3. Review and Edit Activity Hierarchy (Form 6)

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 Session Six

Session Six Key Elements:

1. Review Daily Monitoring (Form 1)

2. Review and Edit Activity Selection and Ranking (Form 5)

3. Review and Edit Activity Hierarchy (Form 6)

4. Introduce and Complete Activity Planning (Form 1)

Review Daily Monitoring (Form 1)

We will begin this session by reviewing your Daily Monitoring Forms (Form 1) from the

past week. It is important to notice the types of activities you are doing and if they are enjoyable,

important, both or neither. What changes if any have you noticed since the first week you started

monitoring?

Review and Edit Activity Selection and Ranking (Form 5)

Now we should be sure that you have completed your rankings of activities. If not, let’s

complete this now. Are there any activities that should be broken into smaller steps? This can

reduce the difficulty level of an activity, because the smaller steps will probably be less difficult

than the entire activity as a whole. Consider doing this if you find you have too many difficult

activities on your list.

Review and Edit Activity Hierarchy (Form 6)

With rankings complete, let’s review the Activity Hierarchy. If this is not yet finished, we

can finish this in session now.

Introduce and Complete Activity Planning (Form 1)

Once you have identified the 15 target activities, you will need a plan for how you will

include these activities into your life and how you will monitor your progress. We will use your

Daily Monitoring Forms for the upcoming week to help you plan your new activities. To begin

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with, you will begin with 2-3 activities to focus on during the next week. Your opinion will be

critical in deciding how many activities to select and it is important that you challenge yourself

without becoming overwhelmed. Be sure to start with the first 2-3 easiest activities. Once you

have decided on the activities you will do for the next week, take your blank Daily Monitoring

Forms for the week and schedule those activities in on the day and time that you think you could

do them. For example, if your activity is to play with your daughter you might enter that activity

(Form 1) at 11am on Monday, 10am on Wednesday, and 9am on Thursday.

It’s important to consider if you are ready for a particular activity. If you are not, you may

wait for another week to do it. However, you could select a smaller step towards accomplishing a

larger activity. For example, if your goal is to exercise, you first might have to buy equipment or

find out where you can exercise. You also might need to find a partner to exercise or find a ride if

you will exercise away from home. So instead of starting with exercise, your activity for the first

week could be go to the store for shoes on Wednesday at 11am and to invite a friend to exercise

on Saturday at 10am. By doing these activities, your ability to start an exercise routine in a few

weeks will be greatly increased. You must understand that it is very important to plan your

selected activities including the time and days you will do it. By planning a day and time you will

find that you are more likely to accomplish the activity.

During the upcoming week, you will complete the Daily Monitoring form just as you have

been doing each day. However, when the time comes for the planned activity, circle the activity in

your form if you complete it. If you do not complete it, cross it out and write in whatever you did

do. It is ok if you are not able to do an activity on a particular day or at the time you had

originally selected. If you cannot do an activity on the day or time that it is planned, just cross it

out and then write the activity you did at that time instead. You can try and do the activity at

another time. We will review your Daily Monitoring Forms next week as usual, but this time we

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will look for the activities you planned, how you felt when you did them, how important and

enjoyable they were, and if you encountered any problems trying to accomplish them. We can

work together to address whatever challenges arise.

If you begin to complete your activities, you will begin to accomplish the values you have

set out for yourself in important life areas. In this way, you will be living a fuller life and feeling

better about yourself as well as feeling less depressed. So, do not worry too much about the

values and life areas for now- just focus on completing activities and the rest will happen naturally.

Assignments:

1. Complete Daily Monitoring with Activity Planning (Form 1)

Session Seven

Session Seven Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Introduce and Complete Contracts Part 2: Getting Help from Supportive People

(Form 2: Bottom Part)

3. Review and Complete Activity Planning (Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your first complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Were you able to complete your planned activities at the planned times and

days? If not, were you able to do it on other days? If you did not complete an activity at all, it is

important to consider why. Was it because you really do not want to do that activity after all? If

this is true, then maybe you can replace this activity with another activity. On the other hand, did

you encounter challenges that prevented you from doing the activity- even though you wanted to

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do it? If this is true, maybe you can find ways to get help. Next we will consider how your

Contracts from Session 2 can be helpful in this way.

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Introduce and Complete Contracts Part 2: Getting Help from Supportive People (Form 2:

Bottom Part)

In Session 2, you completed the top part of Form 1 by listing supportive people (one copy

for each supportive person). As you begin to plan and follow-through on your activities,

you can use that list to write how these people can help you with your activities. This

would be most helpful when there is an activity you want to complete but there are

problems that prevent you from doing it. These Contracts are your chance to decide how

your supportive people can help you overcome these problems. You might realize there

are people you did not think to list in Session 2, and you may add that new person now.

Once you complete the bottom part of the Contract for a person, you may talk with that

person about the help you need. You may show the person the written Contract, but if you

prefer you do not need to show them the Contract. Instead you can just use the Contract

to help you talk with that person and tell them what you need.

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 What we will do in this session is you will identify an activity that you feel you could use

help to complete. For example, you might need help getting yourself to go to the grocery

store each week. Of the people you listed in your Contracts, who would be the most

helpful with this activity? Once you have selected the right person, think of specific ways

they might help and list these ways that person might help below the activity (see bottom

part of Form 2). For example, you might ask them to accompany you to the grocery store

on Saturday. Once you have identified the activity and listed one or more ways the

supportive person can help, the next step is to ask that person if they would be willing to

do this for you. You should definitely complete the Contract, but as said above, it is your

choice whether you show the person the actual Contract or simply discuss what you need

with them. You might find that involving others in your activities makes the activity more

enjoyable. Involving others can also strengthen the support they provide in your life. All of

these things will have a positive impact on the way you feel every day.

Review and Complete Activity Planning (Form 1)

Based on our discussion this session, you should now plan your activities for the following

session week. If you are able, try to plan for 1 or more new activities for the upcoming week in

addition to the activities you accomplished the previous week. I can help you with this exercise,

but remember to go at your own pace.

Assignments:

1. Review and Edit Contracts Part 2: Getting Help from Supportive People (Form 2:

Bottom Part)

2. Complete Daily Monitoring with Activity Planning (Form 1)

Session Eight

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Session Eight Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Review and Edit Contracts Part 2: Getting Help from Supportive People (Form 2:

Bottom Part)

3. Review and Complete Activity Planning (Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Are you finding that you feel better when you are more active? If so, this is

good progress. If not, make sure that your activities are high in Importance, or Enjoyment, or

both. Sometimes people will increase their activities, but find that the activities they selected do

not feel as important or as enjoyable as they first assumed. Notice the Importance and Enjoyment

ratings you gave the activities you planned. Instead, are you finding it is difficult to accomplish the

activities you planned? If so, you might consider breaking those activities into smaller steps as we

discussed in Session 6. It is very useful to consider small steps that can be accomplished that

move you closer to the larger, more difficult activity.

Review and Edit Contracts Part 2: Getting Help from Supportive People (Form 2: Bottom

Part)

Were you able to accomplish at least one behavior Contract? If not, it might be helpful to

discuss the challenges you encountered. What made it difficult? If you are still finding it difficult

to identify a supportive person, perhaps a place to start is to plan some activities that will help you

build a more supportive network of friends. For example, are there people in your community that

are your age and have had similar experiences as you? Perhaps there are ways to get to know

these people better. Another idea is to identify places you can go where you will meet people who

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are similar to you. Then you can plan activities around visiting these places. If you were able to

complete a behavior Contract, how did it go? If you found this to be a good experience, you

might consider using Contracts for other activities as well. If you are still having trouble, it might

be useful to take some time in this session to further review Contracts with your therapist.

Review and Complete Activity Planning (Form 1)

At this point, you might find that you want to make changes to the 15 activities in your

hierarchy. Often new activities come to mind or you change your mind about activities you

originally put on your hierarchy. You should feel free to change the hierarchy each week if you

would like, adding new activities, changing them, breaking them into smaller steps if necessary, or

removing some that you no longer want to include. Overcoming depression is a process, and as

you begin to feel better your plans for yourself may change. You might find it easier to be more

active and set increasingly difficult activity goals. On the other hand, you might feel that your

original plan was too difficult and have new ideas on how to reduce the difficulty of your

activities. Do not feel stuck with your original plan, because it is always open to change. The

important thing is that you are increasing your activity level and as you do this your depression is

improving. It is impossible to live an active, fulfilling, and enjoyable life and be depressed at the

same time. The idea is to increase the amount of time you spend in healthy, active, fulfilling, and

enjoyable activities so that this is what your life is about instead of your life being about

depression.

Assignments:

1. Complete Daily Monitoring with Activity Planning (Form 1)

Session Nine

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Session Nine Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Review Concept and Edit Life Areas and Values (Form 3)

3. Complete Activity Planning (Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Are you finding that you feel better when you are more active? If so, this is

good progress. If not, make sure that your activities are high in Importance or Enjoyment or both.

Sometimes people will increase their activities, but find that the activities they selected do not feel

as important or as enjoyable as they first assumed. Notice the Importance and Enjoyment ratings

you gave the activities you planned.

Are you finding it is difficult to accomplish the activities you planned? If so, you might

consider breaking those activities into smaller steps. Think about small steps that can be

accomplished that move you closer to the larger, more difficult activity.

Review Concept and Edit Life Areas and Values (Form 3)

In session 3, we spent a lot of time talking about Life Areas and Values. Today, I would

like to review the concept of values to make sure that the activities that you are accomplishing

still seem consistent with the values you mentioned earlier in treatment. Remember, an important

step in BA involves determining the activities you would like to add to your life. While becoming

more active in life is important, we need to be sure that the activities that you select are ones that

are important and/or enjoyable to you. One way to help identify activities that are important to

you is to think about what you value in life. Let’s revisit each of the life areas and the values you

have in these areas. Remember, a value is something that is important to you in your heart about

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that life area. Review your values for: Family Relationships, Social Relationships, Romantic

Relationships, Education/ Training, Employment/ Career, Hobbies/ Recreation, Volunteer Work/

Charity/ Political Activities, Physical and Psychological Health Issues, Spirituality, and Daily

Responsibilities. Think about how much the activities you have been doing and planning in the last

few weeks fit into your values. Are there new values that have come to mind? Are the activities

consistent with the values you mentioned?

Complete Activity Planning (Form 1)

Once again, plan for 1-2 additional activities on your hierarchy and write them on your

Daily Monitoring Forms for the coming week.

Assignments:

1. Complete Daily Monitoring with Activity Planning (Form 1)

Session Ten

Session Ten Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Review Concept and Edit Activities (Forms 4, 5, and 6)

3. Complete Activity Planning (Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Are you finding that you feel better when you are more active? If so, this is

good progress. If not, make sure that your activities are high in Importance, or Enjoyment, or

both. Sometimes people will increase their activities, but find that the activities they selected do

29
not feel as important or as enjoyable as they first assumed. Notice the Importance and Enjoyment

ratings you gave the activities you planned.

Are you finding it is difficult to accomplish the activities you planned? If so, you might

consider breaking those activities into smaller steps. Just like in previous sessions, think about

small steps that can be accomplished that move you closer to the larger, more difficult activity.

Review Concept and Edit Activities (Forms 4, 5, and 6)

Throughout treatment, you may have added, subtracted, or changed activities in your

activity hierarchy. We can take some time to review how to go about selecting activities to add (as

well as activities to remove or change) from Forms 4, 5, and 6. In general, if you believe that

completing a particular activity would bring a sense of pleasure and/or accomplishment, then it

probably would be good to include it. It is also important to determine which life value each

activity will help to accomplish. Sometimes patients think of activities to accomplish, but the

activities are not relevant to their life values. This is a good reminder to revisit the activities on

your list and to think of the relevant life values. Also, when selecting activities it is important to

remember that they must be both observable by others and measurable. Therefore, a general goal

like "thinking more positive" is not appropriate, but “eating dinner with my mother twice a week”

would be appropriate. This latter activity could be observable and measurable in the sense that

you could meet with her twice per week. Thus, if these two conditions are met, you have

identified an acceptable activity. Another thing to keep in mind is that it is sometimes tempting to

select very difficult activities for which the benefits are very delayed or uncertain. For example,

having your own home is a long-term goal. To address this potential problem without limiting

your ambition, select activities across a range of difficulty from easy activities you are currently

doing through extremely difficult activities that will take some effort and possibly several

intermediate steps.

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Complete Activity Planning (Form 1)

Once again, plan for 1-2 additional activities on your hierarchy and write them on your

Daily Monitoring Forms for the coming week.

Assignments:

1. Complete Daily Monitoring with Activity Planning (Form 1)

Session Eleven

Session Eleven Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Review Concept and Edit Contracts (Form 2: Top and Bottom Part)

3. Complete Activity Planning (Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Are you finding that you feel better when you are more active? If so, this is

good progress. If not, make sure that your activities are high in Importance or Enjoyment or both.

Sometimes people will increase their activities, but find that the activities they selected do not feel

as important or as enjoyable as they first assumed. Notice the Importance and Enjoyment ratings

you gave the activities you planned.

Are you finding it is difficult to accomplish the activities you planned? If so, you might

consider breaking those activities into smaller steps. Think about small steps that can be

accomplished that move you closer to the larger, more difficult activity.

Review Concept and Edit Contracts (Form 2: Top and Bottom Part)

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In Session 2, you completed the top part of the Contracts (Form 1) by listing supportive

people (Top part of Form 2) and in Session 7 you began to use the Contracts to help

complete some of your activities (Bottom part of Form 2). It would be helpful to take

some time to review how well the Contracts are going. At this point, have you been able

to identify at least one supportive person? Have you been able to get this person’s help

with any of your activities? Remember, engaging the supportive people around you to help

you accomplish healthy activities will not only make the activities easier to accomplish but

will also help to strengthen your support system. Contracts are a way to get your

supportive people to help you overcome depression. As we discussed before, sometimes

supportive people in our lives would like to help us, but they either do not know how or

they tend to do things for us that they think are helpful but are not actually helpful. For

example, sometimes support people will take over your responsibilities because they see

what a hard time you are having now. In other cases, support people will nag or push you

to do things you are not ready to do. In both cases, the support person wants to help, but

is doing things that are not helpful. Contracting will help you to ask support people for

specific ways they can help. Again, it is not important that you show the support person

the written Contract, just that you have a discussion with the person about the specific

ways they can help.

If you have not yet tried a Contract, here is how to do get started. First, identify an

activity that you feel you could use help with. Of the people you listed in your Contracts,

who would be the most helpful with this activity? Once you have selected the right person,

think of specific ways they might help and list them below the activity. Once you have

identified the activity and listed one or more ways the supportive person can help, the next

step is to ask that person if they would be willing to do this for you.

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Complete Activity Planning (Form 1)

Once again, plan for 1-2 additional activities on your hierarchy and write them on your

Daily Monitoring Forms for the coming week.

Assignments:

1. Complete Daily Monitoring with Activity Planning (Form 1)

Session Twelve

Session Twelve Key Elements:

1. Review Daily Monitoring with Activity Planning (Form 1)

2. Prepare for Termination: Continuation of Daily Monitoring with Activity Planning

(Form 1)

Review Daily Monitoring with Activity Planning (Form 1)

Let’s review your complete set of 7 forms of Daily Monitoring with Activity Planning for

each day last week. Are you finding that you feel better when you are more active? If so, this is

good progress. If not, make sure that your activities are high in Importance or Enjoyment or both.

Sometimes people will increase their activities, but find that the activities they selected do not feel

as important or as enjoyable as they first assumed. Notice the Importance and Enjoyment ratings

you gave the activities you planned.

Are you finding it is difficult to accomplish the activities you planned? If so, you might

consider breaking those activities into smaller steps. Think about small steps that can be

accomplished that move you closer to the larger, more difficult activity.

Prepare for Termination: Continuation of Daily Monitoring with Activity Planning (Form 1)

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 Congratulations! We have done a lot of great work together throughout treatment and you

have accomplished so much. You have worked very hard! When we look back at your Daily

Monitoring (Form 1) from the first week of treatment and compare them to your Behavioral

Monitoring with Activity Planning (Form 1) from the last week of treatment, what do you see?

(You should directly compare the first and last week of behavioral Monitoring). At this point, you

have learned a number of skills that can help you feel better and live healthier when you begin to

feel depressed again. Should depressed feelings return it will be helpful to review this manual and

practice all of the skills again, and you might consider continuing to do the skills and monitoring

as a part of your life regardless of how you feel!

Finally, it is important to remember that depression cannot exist when you live a healthy,

meaningful, and fulfilling life. No matter what has happened to us in the past, it is possible for

every one of us to make changes to our lives, to make the best of our circumstances, and spend

our time doing activities that give us as much purpose, meaning, and enjoyment as possible. Good

luck to you in all of your future endeavors.

Assignments:

1. Continuation of Daily Monitoring with Activity Planning for the Future (Form 1)

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 List of Forms

Form 1. Daily Monitoring (with Activity Planning starting in Session 6)

 Therapist Manual: One copy

 Patient Manual: 84 copies (one for each day of treatment)

Form 2. Contracts

 Therapist Manual: One copy

 Patient Manual: 10 copies

Form 3. Life Areas Assessment

 Therapist Manual: One copy

 Patient Manual: One copy

Form 4. Life Activities Checklist

 Therapist Manual: One copy

 Patient Manual: One copy

Form 5. Activity Difficulty Assessment

 Therapist Manual: One copy

 Patient Manual: One copy

Form 6. Activity Hierarchy

 Therapist Manual: One copy

 Patient Manual: One copy

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