Question 1

Hi Shirley, do you have any ideas for behavioral activation activities to do in the actual therapy room with kids?

Shirley Reynolds · Accepted Answer

Oh yes, these are endless.  They should always relate to the young person’s values, i.e. ‘What matters to them.’   So make sure you establish what matters to the young person first.   Next, the activities should be developed in collaboration with the young person.   Don’t forget depression might get in the way of the young person having new ideas, so it’s fine to help, make suggestions, encourage and support them. Here are a few examples to stimulate your own ideas and your collaboration with the young person.
Life area – Me (health), Value – Get more exercise, Valued activity - Get up and go for a walk with the young person right now - Check when there is a yoga class at their local gym and help them to book a session online - Text a friend to arrange at time to walk the dog
- Download the ‘Couch to 5K’ app on their phone - Do some high intensity exercises together in the session – eg. Star jumps, mountain climbers, high knees
Value – Find time for yoga, Valued activity – Do some yoga in the session
Life area - Me (hobbies), Value -Listening to music, Valued activity 
- Find favourite band online and play one of their tracks in the session - Use Spotify to identify a new group or musician based on previous listening – play in the session
Life area - The big picture (work), Value - Find a part-time job, Valued activity 
- Enrol on a recruitment site or sign up online with a local recruiter (e.g., supermarket)
- Search a job site and send an email to one employer 
Life area - The big picture, Value - Support environmental causes , Valued activity
- Explore what environmental groups are available locally - consider sending a text or email or joining an activity
Life area - The big picture (education), Value - Learn a new language, Valued activity 
- Download Dualingo app - complete lesson 1 in session
Life area - The big picture (work/education), Value - Learn how to code, Valued activity 
- Join an online free course run by FutureLearn (enrol during the session)
Life area - The people that matter, Value - Be a good friend, Valued activity - Send my friend a text with a funny gif - Invite my friend over to listen to music (or something we both enjoy)
Value - Be nicer to my little sister, Valued activity - Send sister a text offering to help her with her maths homework (or least favourite homework)
Value - Be a good grandson, Valued activity - Phone my grandmother right now for a chat

Setting up the activity is important to make sure that you and the young person learn as much as possible from it.  Before the young person starts the activity ask them to rate their mood ‘right now’.   This can be as easy or complicated as you like – use smiley faces (sad, neutral, happy), or something more complex like a 1-10 scale (1 = totally unhappy, 10 = totally happy).

Once the young person has done the activity, make sure that you praise them (positive reinforcement).  What do you notice from their behaviour or demeanour?  What do they say or tell you?  Ask the young person to rate how they feel ‘right now’.  Using the same scale as you did before the activity has their rating changed?  If so what do they think that means?  If not, explore possible reasons.   Agree to try out a few more things to see if they have any impact on their mood.  Always be curious, whatever the young person can tell you is important and interesting so make sure you pay attention.

If you would like to learn more about how to deliver Brief Behavioural Activation for adolescent depression you can join our online workshop – find out more here 
https://www.cbtreach.org/pass-reynolds
You can also learn more about Brief BA in the following references
Treatment manual for Brief Behavioural Activation
Reynolds, S., & Pass, L. (2020). Brief behavioural activation for adolescent depression: A clinician’s manual and session-by-session guide. Jessica Kingsley Publishers
Research on the experience of Anhedonia in adolescents, treatment of anhedonia in Brief BA, and experience of Brief BA treatment 
Watson, R., Harvey, K., McCabe, C., & Reynolds, S. (2020). Understanding anhedonia: A qualitative study exploring loss of interest and pleasure in adolescent depression. European child & adolescent psychiatry, 29(4), 489-499
https://link.springer.com/article/10.1007/s00787-019-01364-y
Watson, R., Harvey, K., Pass, L., McCabe, C., & Reynolds, S. (2021). A qualitative study exploring adolescents’ experience of brief behavioural activation for depression and its impact on the symptom of anhedonia. Psychology and Psychotherapy: Theory, Research and Practice, 94(2), 266-288.
https://bpspsychub.onlinelibrary.wiley.com/doi/pdfdirect/10.1111/papt.12307
Lewis-Smith, I., Pass, L., Jones, D. J., & Reynolds, S. (2021). "… if I care about stuff, then other people care about me". Adolescents’ experiences of helpful and unhelpful aspects of brief behavioural activation therapy for depression. Psychotherapy Research, 1-12.
https://www.tandfonline.com/doi/pdf/10.1080/10503307.2021.1898692
Using Brief BA in schools
Brett, S., Reynolds, S., Totman, J., & Pass, L. (2020). Brief behavioural activation therapy for adolescent depression in schools: two case examples. Emotional and Behavioural Difficulties, 25(3-4), 291-303.

Question 2

Sometimes motivation and energy are so low, that even when taking a gradual approach to activation, patients fail to do the assigned activities. How do you deal with such roadblocks to compliance?

Shirley Reynolds · Accepted Answer

Yes, depression is often characterised by very low levels of motivation and energy, as well as fatigue,  hopelessness and feeling worthless or useless.  These are incredibly difficult barriers for young people to overcome.  In addition, depression is associated with memory and attention problems. These difficulties should not be underestimated and need to be factored into how therapy is delivered.   Brief Behavioural Activation has been developed to try to overcome these barriers.  We would not see an unsuccessful task as an issue of ‘compliance’ but as something that is a direct consequence of depression.

We use a number of techniques to support young people who have these common difficulties.  First, we work hard to build a strong and collaborative therapeutic alliance with the young person.   We share a model of depression that young people can easily relate to.  We tell them that although the Brief Behavioural Activation model is ‘Simple, it’s not easy’.  We anticipate that change is hard and acknowledge that if it wasn’t, they wouldn’t need our help.  We acknowledge how horrible it is for them right now and how difficult it is to change.

We reinforce as much non-depressed behaviour as we can.   This may include the young person coming to the therapy session, looking at the therapist, answering a question, giving information, asking a question, completing routine outcome measures and, of course, completing a therapy task.  We pay close attention to their verbal and non-verbal behaviour.  We are interested, curious and want to know more about them.  Being interested and curious in a young person shows them that they are important to you  - this can help counter their feelings of worthlessness and hopelessness.

We present Brief Behavioural Activation as highly collaborative.   We engage social and emotional support that the young person has (e.g., parents, teachers, older siblings) and use these people to ‘scaffold,’ i.e., to support the young person taking difficult steps to do more that matters to them.  We also structure therapy to take advantage of early hope and optimism – we recommend that the first 4 sessions are scheduled with 2 sessions per week.  This provides a degree of momentum to the start of therapy and offers more opportunities for the therapist to provide positive reinforcement and get therapy going.

Our focus on ‘What matters to you?’ is highly personal and we find, very engaging to young people. It links them to where they are now and to their future self – who they want to become.    However, even when young people understand the Brief BA model and want to change – change is hard.

For this reason, we introduce and try out ‘valued’ activities in the therapy session.   The therapist helps the young person to identify a behaviour they can complete right now.  This could be sending a text message to a friend, listening to a favourite piece of music, finding information on the internet, going for a walk outside, or downloading an app.  There are endless opportunities if the young person has a mobile phone, but valued activities need not be limited to these.

Because the young person completes a small but valued activity during the session, they experience a sense of achievement, and often, they also feel some (small) positive affect.  The therapist is curious about this.   Having made a small start in the session to do ‘more that matters’ the young person is in a better place to do something similar between therapy sessions.   Therapists need to identify a similar, manageable, and rewarding activity that the young person can do outside the session.  They may also need to identify possible barriers and explore how to remove them as well as to recruit practical and emotional support to help the young person succeed.   And of course, because any task we ask a young person to do is important, we always make sure we check how it went at the next session.

Even the best laid plans can be unsuccessful.  When tasks are not completed between sessions, we conceptualise this as a problem with the planning of the task, not with compliance.   Therefore any ‘failure’ lies with the therapist, not the young person.  Perhaps the task was poorly planned, the therapist’s instructions were ambitious, the activity didn’t matter to the young person, or the therapist didn’t spend time making sure that they anticipated the problems.   By exploring the mistakes that the therapist made setting up the task, it’s possible for young people to feel less blamed, to be less defensive and to consider, with the therapist, how to overcome the difficulties next time.

Question 3

Are there any apps that you would recommend for behavioral activation?

Shirley Reynolds · Accepted Answer

We don’t use or recommend any apps – I’m sure there are great ones, but there is no quality control process and the market constantly changes.   Young people often find online apps to keep activity diaries – if this is useful for them, it’s a great step in being independent. We would always praise their efforts to find suitable apps or other methods to use.

Question 4

Is behavioral activation more than just pleasant/mastery experiences scheduling?

Shirley Reynolds · Accepted Answer

Yes!  In Brief Behavioural Activation the key concept is ‘Do more that matters’.  So we focus our attention on doing specific activities that are important to the young person, rather than things they have to do, or that other people want them to do.   This is a very important aspect of Brief BA – we want the therapy to be for and about the young person and under their control.   ‘Doing more that matters’ also means that the activities that young people then do are likely to be rewarding.  Mastery (achievement) and pleasure are important – we also ask young people to consider if valued activities help them to feel close to others.

This focus on ‘what matters to you’ is extremely important at a time when young people are developing their identity and exploring who they want to be.    Where possible Brief BA will also use other people to support the young person, for example, their parents, other family members, or teachers – however, the focus is always explicitly on what matters to the young person, and not on what matters to other people.

Question 5

What is the difference between behavioral experiments and behavioral activation?

Shirley Reynolds · Accepted Answer

Behavioural experiments are an important part of cognitive behaviour therapy. They are planned activities that are used to test out hypotheses or predictions that people make.  They are used to gather information or ‘evidence’ which is then used to test if a belief or prediction is accurate.    Behavioural experiments are therefore a core part of cognitive behaviour therapy.   There is a very helpful article about Behavioural Experiments here

https://www.karger.com/Article/FullText/511921

Behavioural Activation is used to describe a complete model of therapy – There are different forms of Behavioural Activation, varying in length and complexity.  Brief Behavioural Activation (Brief BA)  has been designed as a self-contained treatment for adolescent depression (6 to 8 sessions) that aims to identify and then increase valued activities, to increase rewards (positive reinforcement), and therefore improve their positive affect (mood).

Question 6

Is there any cognitive work involved in BA for depression?

Shirley Reynolds · Accepted Answer

No, the Brief BA model is a behavioural model and we do not include any cognitive work.  This is for a number of reasons, including the need to keep the model as simple as possible.   Young people with depression typically have impaired working memory and other cognitive problems.  These can make it very hard for them to engage in abstract thinking, much of which characterises cognitive work.  We also aim to keep the model simple and brief so that it can be delivered in a range of settings by a range of clinicians, including low intensity clinicians.   For this reason, we would ideally see Brief Behavioural Activation as part of a stepped care model that leads to alternative evidence-based interventions if Brief BA is not adequate.

Question 7

Is there a standardized measure to help people, especially adolescents, identify their values?

Shirley Reynolds · Accepted Answer

We tend to use a simple table to help young people identify their values.   There are three headings – ‘Me’ ‘The bigger picture’ and ‘Other people’.  In each column there are 3 (or 4) boxes that provide general areas that might be important.  For example, in the ‘Me’ column the boxes might include – Health, Hobbies, and  ‘Self-care’, in ‘The bigger picture’ they can include ‘School/college’ ‘Work’ and ‘the wider world’.

These simple prompts seem to provide enough to stimulate ideas and discussion with the therapist.   You can see an example of Jeni using this simple tool with Emma here

https://www.youtube.com/watch?v=9fQM-QxBxEI

Question 8

What do you do when a young person's values and goals differ from their parents' expectations of them, especially in relation to academic achievement, career choice and how they spend their time? Thank you!

Shirley Reynolds · Accepted Answer

We always aim to involve parents in Brief BA so that they can understand the model and support their son or daughter to increase valued activities.  It also helps for the clinician to provide psychoeducation for parents and young people about normal adolescent development as well as about depression.

As we discuss with parents, adolescence is a period of life when we explore who we are and develop our individual identity.  As part of this development young people become less dependent upon their parents and more attached to their peers.   Young people may develop values and beliefs that differ from their parents, although most young people we have spoken to recognise that they develop values based on their family, culture, their education, and their friends.

Parents often express concern about the activities that their son or daughter is doing.  
The most common conflict between parents and young people is about screen time.  Parents typically say that their son or daughter is spending too much time on computer games, or social media.  Young people often say that this is an important activity for them and that it is helping them spend time with their friends, or helping them relax, or learn new skills.    The video here shows Jack and his parents discussing a conflict with Laura.

https://www.youtube.com/watch?v=ymLk9b9t-20

When conflicts occur between young people and their parents it is helpful to focus on the young person’s values rather than on the behaviour or activity.   This can help parents understand why a behaviour or activity is important to the young person.   It can also help the young person to identify alternative or additional activities and behaviours that link with the underlying value.

Question 9

How do you "sell" or explain BA to teens?

Shirley Reynolds · Accepted Answer

Brief Behavioural Activation is a very simple approach.   This is deliberate because we want the ideas to be easy for young people and their parents to understand.  Here is a video showing Laura explaining the model to Jack and his mum Kirsty.  As you will see we use a simple diagram to show how the model works and Laura uses descriptions and language used by Jack to show how it might apply to him.

https://www.youtube.com/watch?v=_gm-uXGESkg

When we explain Brief BA to young people (and their parents) we tell them that ‘It’s simple, but it’s not easy’.  This means that although the ideas are ‘simple’ making the changes is not so simple. As Laura says in the video if it was that easy Jack would already have made the changes.

We always explain the model in different ways – for example before the young person comes into treatment we will send them some information.   Then in the first session, we will describe the model to them, as in the video.   Then they also get a copy of the model, with their own language and situation included in their handout.  During the treatment, the therapist will come back to the model to remind them how it works and how it applies to them.

Question 10

How do you help adolescents discover what matters to them? And how do you help them when they don't feel like they have much control in their life?

Shirley Reynolds · Accepted Answer

This is a great question.  Brief Behavioural Activation for Adolescent Depression (Brief BA) is all about doing ‘More that Matters’.   Therefore, as an essential early part of treatment, we spend time exploring what ‘matters’ to the young person.   ‘What matters to you?’ is a question that most young people find very intriguing.   We think this is because adolescence is a period when we develop and refine our sense of ‘self’ or who we are.   This period of identity formation is critical because ‘what matters to me’ will inform decisions about relationships, education, work, and social activities.

Most young people find it quite easy to talk about ‘what matters to them’.  We have done some work with young people to explore their understanding of values (i.e., what matters to them).   Almost all engaged easily in the conversation and had very clear views about what their values were, where their values came from, and why values are important.  You can read more about this research here 
https://journals.sagepub.com/doi/full/10.1177/1359104520964506

So most young people don’t need special help to talk about what matters to them.  But it can be helpful to provide support.   For those who do need a bit of help, we use information from their activity logs.  Activity logs are used to record what young people do and if it was enjoyable or helped them feel close to someone or that they achieved something.   These are important clues to what might matter to them.  We also use examples of young people and their values; these are included in our manual for young people so they always have them to refer to.   This is a link to the full clinical manual for Brief Behavioural Activation which has session guides, activity logs, and handouts for young people and their parents  
https://www.hachette.co.uk/titles/shirley-reynolds-4/brief-behavioural-activation-for-adolescent-depression/9781787755031

Another useful way to discover what matters is to focus on three areas – the self, the ‘bigger picture’ and other people.   For example, in the ‘self’ area, does it matter to you that you look after your health?  If so, how can you do that?  In the ‘other people’ area, who matters to you?   What kind of relationship do you want to have with them?  In the ‘bigger picture’ what areas of work or education matter?   Are you religious?  Do you have strong beliefs about politics, the environment, or anything else?

Here is a video showing Jeni, one of our trainees, Jeni, working with Emma (aged 13) to help her work out what matters to her. 
https://www.youtube.com/watch?v=9fQM-QxBxEI

Young people do have less control in their lives than adults.   Sometimes they can’t do some of the things that matter to them right now.    For example, if they want to go and live in another country, they can’t do that until they are an adult.  But right now, they can spend time learning about the culture, food, and language of the country and planning what education or training they will need to make it possible for them to work there.   Other things that also matter to them might be more under their control, for example, ‘being a good friend’, ‘taking care of my health’, ‘learning how to play the guitar’.   We encourage young people to identify a range of different things that matter to them so that they have lots of different valued activities they can do.

Behavioral Activation for Teenage Depression