Just doing it: Behavioural Activation

This post is sparked by a pre-print paper I read yesterday, but follows a long time cogitating about the use and value of “just doing it”.

Behavioural reactivation is a set of techniques often used for mood management.  It usually incorporates activity monitoring, assessment of life goals and values, activity scheduling, skills training and problem solving, effective communication training, relaxation training, contingency management, and managing things like avoidance.

Fellow occupational therapists will probably feel a tad superior here because these are core aspects of the ways in which occupational therapists work with people, but beware troops! The research from psychology is vast, and it’s rapidly gaining recognition as a psychological approach to reactivation.

Behavioural activation strategies are pretty old as far as rehabilitation techniques go.  In fact, the literature in psychology goes back to the 1970’s with Lewinsohn’s work on pleasant event scheduling.  Occupational therapists, I need to add, have used activities as therapy since the early 1900’s.  There have been numerous more recent studies on aspects of behavioural activation, but in the light of the flourishing CBT and cognitive therapies, the value of behavioural approaches has sometimes been lost.

While the majority of work has been studying behavioural activation in mood management, there is reason to consider its use in pain management.  Not only do the two populations often have similarly low levels of activity, there is a good deal of cross-over in terms of diagnosis (people with chronic pain often have low mood, people with low mood often have chronic pain), symptoms can be quite similar (slowed movements, lack of energy, loss of enjoyment in doing things) and even pharmacological management of certain types of low mood and chronic pain disorder.

The basic techniques of behavioural activation vary from research study to research study, and like many techniques, the specifics of each technique can vary too.  Despite this, and the current paucity of research into its use in chronic pain management, I think there is something to be gained by taking a closer look at these techniques, and considering their use in pain management – maybe even generating some good research into their application and effectiveness.

Activity monitoring – this usually involves recording daily activities in some sort of diary format.  By doing this it offers both therapist and participant a look at baseline activity levels, and to explore the relationship between activities, emotions, thoughts and aspects of wellbeing such as role fulfilment, balance in life, and the distribution of activity throughout the day.  Activity monitoring isn’t seen as a specific behavioural intervention, but rather as an assessment or monitor to support behaviour change – despite this, simply by recording activity, behaviours do change.  (Don’t believe me? Try recording your eating for a day…!)

Assessing goals and values – this involves reflecting on life roles or domains in order to identify values within each domain.  These values are then used to guide activation ‘assignments’, or the specific activities that can be used within activity scheduling.  Sounds a lot like COPM to me!  But many variants are able to be used, and it seems that the research within cognitive therapy strangely enough supports the behavioural reinforcement role that values can have within a behavioural activation approach.  Values underpin ‘important’ activities, and provide internal motivation as the activities carried out enact those values.  The ‘feel good’ factor of doing what you say you will, if you like.

Activity scheduling – now many people will know how much I loathe the word ‘pacing’ because of its connotations of ‘doing less’, or ‘doing things until just before your pain flares up’, so now I can feel quite justified in adopting the term activity scheduling because, as used in behavioural activation, ‘scheduling’ means just that.  As used by Lewinsohn, activity scheduling is intended to bring about contact with positive reinforcement in the environment.  In pain management, it also involves spreading activities out throughout the day to enable the person to maintain consistent activity patterns rather than erratic or deactivated patterns.  Pleasant event scheduling is one of the early forms of activity scheduling, and can be useful when an individual is just learning to become more active, but isn’t the only type of activity that can be scheduled.  In fact I often find it hardest to help someone develop the skill to schedule ‘time out’ for relaxation!  Activity scheduling is one sure-fire way to access automatic thoughts if you’re integrating a cognitive approach with a behavioural one too.

Skills training – strategies like developing assertive communication, relaxation training, role playing etc are included in behavioural activation because while many people can simply ‘do’ the activities, others may need support to carry them out skillfully – and in doing activities may also encounter issues with other people and may need to problem solve to enable them to carry out the activities consistently.

I couldn’t find a behavioural activation paper in chronic pain management, but I did find this paper by Dimidjian,  Hollon, Dobson, et al. (2006) that I particularly liked because of both its design, and the examination of symptom severity with treatment outcome.  It’s difficult to know whether a similar study could be carried out in pain management, especially in New Zealand, because of the complexity of the ways we manage pain (multiple clinicians, multiple medications etc).  But I can dream – and one day hope that this aspect of pain management will get the attention it deserves.

Lewinsohn, P., & Libet, J. (1972). Pleasant events, activity schedules, and depression.  Journal of Abnormal Pyschology, 79, 291-295.

Lewinsohn, P., Weinstein, M., & Alper, T. (1970). A behavioral approach to the group treatment of depressed persons: a methodological contribution.  Journal of Clinical Psychology, 4, 525-532.

Dimidjian, S., Hollon, S., Dobson, K., Schmaling, K., Kohlenberg, R., Addis, M., Gallop, R., McGlinchey, J., Markley, D., Gollan, J., Atkins, D., Dunner, D., & Jacobson, N. (2006). Randomized Trial of Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Acute Treatment of Adults With Major Depression. Journal of Consulting and Clinical Psychology, 74 (4), 658-670 DOI: 10.1037/0022-006X.74.4.658