01 - 7. Activity Scheduling

7. Activity Scheduling

O ne of the most important initial steps for depressed clients is scheduling activities (Cuijpers et al., 2007). Most have withdrawn from and are actively avoiding at least some activities that had previously given them a sense of achievement, control, pleasure, or connection—­ and that lifted their mood. Many stop following their daily routine and do less self-care. Like Abe, they eat less well, exercise less often (if at all), and sleep too much or too little. They frequently increase certain behaviors such as staying in bed, watching television, playing video games, looking at social media, or surfing the internet. This change in activities helps maintain or increase their current dysphoria and the sense that they’re at least somewhat out of control. We get across the following messages: “It’s important to act according to your values, what’s really important to you, instead of what you feel like doing—­because depression makes you tired and then you’ll feel like avoiding. But avoidance just makes depression worse. Don’t wait until you feel energetic or motivated to start an activity or task. Do it first. You’ll probably find that you get more energized and motivated some time after you start. “As you’re engaged in an activity, watch out for negative thoughts that can decrease your sense of competence, purpose, and connection to others. Because you’re depressed, at least some of these thoughts are likely to be inaccurate, or at least partially inaccurate. When you’re finished the task or activity, make sure to give yourself credit—­you can just say something like ‘good.’ Recognize that pushing yourself to do something means you’re taking control, even if in a small way, of your depression.” ACTIVITY SCHEDULING

Clients often believe they can’t change how they feel emotionally. Helping them become more active and giving themselves credit for their efforts are essential parts of treatment. Doing so improves their mood and strengthens their sense of self-­efficacy—­they demonstrate to themselves that they can take more control of their mood and behavior than they had previously believed. We usually start collaboratively scheduling activities in the first or second therapy session. In this chapter, you’ll find answers to these questions: How do you conceptualize inactivity? How do you conceptualize lack of mastery and pleasure? How do you schedule activities with clients? How do you use an Activity Chart? How do you help clients track and rate their activities? What types of activities should depressed clients engage in? How do you use an Activity Chart to assess predictions? CONCEPTUALIZATION OF INACTIVITY When considering engaging in activities, clients’ depressed automatic thoughts frequently get in the way.

[Common] Automatic Thought: “I’m too tired.” “I won’t enjoy it.” “My friends won’t want to spend time with me.” “I won’t be able to do it.” “Nothing can help me feel better.” [Common] Emotional reactions: Sadness, anxiety, hopelessness [Common] Behavior: Remain inactive Situation: Thinking about initiating an activity. Cognitive Behavior Therapy: Basics and Beyond

Clients’ relative inactivity then contributes to their low mood, as they have a paucity of opportunities to gain a sense of mastery, pleasure, or connection, which leads to more negative thinking, which leads to increased dysphoria and inactivity, in a vicious cycle. Depressed Mood Negative Thoughts Behavior/Situation: Inactivity/Recognizing Inactivity On the other hand, becoming more active and recognizing that they deserve credit usually lifts their mood and makes it easier to continue being more active. Increased Hopefulness Positive Thoughts Behavior/Situation: Increased Activity/Recognition of Increased Activity

Activity Scheduling

If you think it would be helpful, you can draw these diagrams for clients and add them to their Action Plans to review at home. CONCEPTUALIZATION OF LACK OF MASTERY OR PLEASURE Even when clients do engage in various activities, they often derive low levels of satisfaction and pleasure because of their self-­critical automatic thoughts.

[Common] Automatic Thought: “There’s no point in doing this.” “I’m doing a terrible job.” “I should have done this long ago.” “There’s still so much left to do.” “I can’t do this as well as I used to.” “This used to be more fun.” “I don’t deserve to be doing this.” [Common] Emotional reactions: Sadness, anxiety, guilt, anger at self [Common] Behavior: Stop the activity. Fail to repeat this activity in the future. Situation: Engaging in an activity.

Clients may also have similar negative thoughts after engaging in an activity (“I should have done that better”; “Doing that was just a drop in the bucket”). When scheduling activities, therefore, it’s important to anticipate automatic thoughts that could interfere with clients’ initiation or continuation of activities and thoughts that could diminish their sense of pleasure, achievement, or connection during or after the activity. Cognitive Behavior Therapy: Basics and Beyond

SCHEDULING ACTIVITIES Most clients who are depressed have changed their daily or weekly activities to some degree. It’s important to help them reengage more fully in life. Some therapists ask depressed clients to fill out an Activity Chart (Figure 7.1) early in treatment, noting the activities they do each hour and, if they’re willing, rating their sense of mastery and pleasure. Then they use the information to guide clients in scheduling activities. But not all clients are willing to fill out the chart. And I prefer to have them schedule activities even at the evaluation. That’s why I ask them to describe their activities on a typical day, which gives me enough information to discover which kinds of activities they have been avoiding. Ideally, you’d have enough time in the evaluation and first session to elicit potential activities from clients. If there’s not enough time, you can suggest activities that are in line with your client’s aspirations and values. In subsequent sessions, you might do a combination of suggesting and eliciting ideas. Here’s what I discuss with Abe in our first therapy session. Judith: [being collaborative] Could we talk about how you’ve been spending your time? Are you still sitting on the couch, watching TV, or using your computer a lot? Abe: Yeah, too much. Judith: [collecting data to motivate Abe] What’s your mood usually like after you’ve done that for a couple of hours? Abe: (Thinks.) Pretty bad, I guess. I always feel like I should have been doing something more productive. Judith: Can we talk about some other things you might be able to do this week? I think it’ll be an important step in taking control. Abe: Okay. Judith: [providing the rationale] First, you should know that research shows that if you want to get over depression, you need to become more active. We don’t have a lot of time today, but I wonder if you could think of some things you could do this week. Abe: I’m not sure. [expressing an automatic thought that could be an obstacle] I’m pretty tired most of the time. Judith: Would you be willing to try some things as an experiment? To see whether you’re actually too tired? Abe: Yeah. Judith: For example, what would you think of trying to get out of your apartment, even if just for a few minutes, most days this week?

Activity Scheduling

Aspirations, values, or goals:  Be a better father, husband. Work in the music business. Take better care of my physical and mental   health. Find a spiritual home. Get involved in the community.

  MON. TUE. WED. THU. FRI. SAT. SUN. Name:  Eric L.

  Date:  October 24

Activity Chart, Side One See reverse side for optional rating scales.   7:00 A.M. Sleep   8:00 A.M.   6:00–   8:00–   7:00– 11:00 A.M.– 12:00 P.M. Breakfast, kitchen cleanup (10 min)—3   9:00– 10:00 A.M. Doze off and on—2   1:00 P.M. TV/computer/video games—2   2:00 P.M. TV/computer/video games—2 10:00– 11:00 A.M. Get up/shower/ dress—3   3:00 P.M. Nap—2   9:00 A.M.   2:00– 12:00–   1:00– Morning Afternoon

9:00 P.M. Walk around mall—4   5:00 P.M. Call Natasha—6 Laundry (10 min)—4   4:00 P.M. Lunch, kitchen cleanup (10 min)—3   8:00 P.M. Dinner, kitchen cleanup (10 min)—3   7:00 P.M. TV/computer/video games—2 Laundry (10 mins)—3   6:00 P.M. Errands or take a walk—5   6:00–   8:00–   3:00–   5:00–   4:00–   7:00– FIGURE 7.1.  Partially completed Activity Chart, side 1: Tracking and rating activities. Overall mood ratings on a 0–10 scale.   9:00– 10:00 P.M. TV/computer/video games—2 10:00– 11:00 P.M. TV/computer/video games—2 11:00 P.M.– 12:00 A.M. Get in bed, try to sleep—2   1:00 A.M. Sleep 12:00– Evening

Abe: I guess I could do that. Judith: You could take a 5-minute walk. Or you could go someplace in the car. Abe: Okay. Judith: [making the step more specific] Where could you go? Abe: (Thinks, sighs.) Well, I have to go to the grocery store today. Judith: That’s good. How about the other days? Abe: I suppose I could go to the hardware store. I have to get some light bulbs. Judith: That sounds good. Could you go to other places even if you don’t need anything? The important thing is to demonstrate to yourself that you can start to take more control of your life, that even though you’re tired, you can start reengaging with the world. Abe: Yeah. I understand. Next, I want to make sure that Abe is prepared for the possibility that getting out doesn’t make him feel better. I also reinforce the cognitive model. Judith: Now, I don’t know whether getting out will affect your mood or not. It will depend on what you’re thinking. If you think, “What’s the point of doing this?” or “This is just a drop in the bucket,” how do you think you’ll feel? Abe: Depressed. Judith: I think you’re right. And if you think, “Hey, this is really good. Even though I’m tired, I’m taking control. It’s a really important step,” then how do you think you’d feel? Abe: Better. Judith: Okay. But I don’t want to promise you that getting out will definitely improve your mood. Some people do feel better right away. But for others, it’s like a jack-in-the-box; you know, that toy that you wind up (motions with a circular hand movement) and the clown pops out? Abe: Yeah. My kids had one. Judith: Some people can crank the level only once and the clown pops out—they feel better. Other people need to crank it around and around and around. It can take weeks for the clown to pop out and for them to feel better. But you have to start someplace. Abe: Should I get out of the apartment every day? Cognitive Behavior Therapy: Basics and Beyond

I don’t want to set an Action Plan item that Abe might have difficulty with (and then blame himself), so I propose a range. Judith: Maybe we should say four times this week? So, four times is great, and if you do more than that, so much the better. Abe: Okay. Judith: Should I write this down, or do you want to? Abe: You can. Judith: (Writes it down on Abe’s Action Plan.) Next, I elicit the rationale from Abe and help him respond to automatic thoughts that could pose an obstacle to taking these steps by tying these activities to his aspirations and values. Judith: Now let’s write down why it would be good to do this. Abe: You said it’s a first step, to take control. Judith: Exactly. (Writes that down; then looks for potential obstacles.) Now, what could get in the way? Abe: (Sighs.) If I’m too tired. Judith: You might be really tired. What would you like to say to yourself if you’re feeling really tired? [I ask this question because I sense that Abe would have a good response. With other clients, Socratic questioning might have been important.] Abe: I guess, “Go anyway”? Judith: Good. Go anyway because . . . Abe: Because I need to get back in the world. Judith: How important is it to you to get back in the world? Abe: Very important. Judith: [eliciting his values and aspirations] Why is it important? Abe: So I can get back to work. So I’ll feel useful. So I can be productive. Judith: Anything else? Abe: Yeah, so I can be a better father and grandfather. Judith: Should we write something down about this too? “If I’m feeling really tired and feel like staying on the couch instead of going out—or, I suppose, doing something else—­remind myself . . . Abe: I have to get back in the world. It’s important to go. Not going will probably keep me depressed. Judith: And you want to get back in the world so you can . . .

Activity Scheduling

Abe: Be productive, be better to my family. Judith: When you’re back in the world, will you feel more useful and competent? In control? Have a sense of purpose? Abe: Yeah, all those things. Judith: That’s good. Let me get that down on your Action Plan. (pause) And should we add that going out may or may not affect your mood right away? And if it doesn’t, it just means you need to crank up the jack-in-the-box? Abe: Yeah. Judith: (Writes it down.) Now how likely are you to get out of your apartment—­even if it’s just for a 5-minute walk or a fast trip to a store—at least four times this week? Abe: I’ll definitely do that. Judith: Okay! Now, if you find you just can’t, that’s all right. It just means we probably need to start with something easier. But do try to keep track of the thoughts that get in the way. Abe: Okay. Judith: I’ll add that to the Action Plan too. (Does so.) CLINICAL TIPS If the discussion above isn’t persuasive, you can try the following, as I did with Maria. When Clients Resist Scheduling Activities When I tried to schedule activities with Maria in the first session, she didn’t want to commit to anything specific. I thought pressing the point would impair the therapeutic relationship, so we agreed that she would try to become more active in general. During our review of the Action Plan in the following session, it turns out that Maria hasn’t been able to be more active, so we add that goal to the agenda. I start off by reminding her of the rationale for activity scheduling. Judith: Is it okay if we talk about scheduling some activities this week? Maria: Okay. Judith: Do you remember what we said last week about why that’s important? Maria: Not entirely. Judith: First, research show that an essential part of getting over depression is becoming more active. Second, it doesn’t sound as Cognitive Behavior Therapy: Basics and Beyond

if there’s much you’re currently able to do that brings you much pleasure or helps you feel competent and effective and in control. Is that right? Maria: I guess not. Judith: You know, most people who are depressed think they’ll feel better if they stay in bed. Can I ask you this? Haven’t you already done the experiment of staying in bed, actually for months and months? Has it helped you recover from your depression? [referring to Maria’s aspirations] Has it helped you get to where you want to be in life—­having more friends, working and earning money, having a better apartment, finding a romantic relationship . . . ? Maria: No, it hasn’t. Judith: And if you keep staying in bed, do you think it will suddenly work? Maria: I suppose not. Judith: Would you like to try a different experiment this week? Maria: (Sighs.) I guess so. Judith: We could talk about activities you feel you could do that would be either meaningful or easy. Which do you think would be better? Maria: Maybe both? Judith: Good idea. Okay, here are some categories: self-care, like showering, getting dressed, eating well, and getting exercise. Another category is connecting with people. A third category is managing better at home. A fourth category is recreation or entertainment. So that’s self-care, connecting with people, managing better, and recreation/entertainment. (pause) Which category do you think would be easy and also meaningful? Maria: I don’t see how scheduling activities will help. (a little angrily) My whole life is a disaster. Judith: It’s good you told me that. I probably should have explained some more. You’re absolutely right. You have big problems that you need help in solving. But here’s what I’ve found. When people are as depressed as you are, trying to solve really big problems becomes overwhelming. That’s why it’s better to start with small things and build up your confidence by showing you that you can take control of parts of your life and that you can be effective. That’s why the small steps are important. Maria: (Sighs.) Oh.

Activity Scheduling

Next, I remind Maria about her aspirations and how achieving those aspirations would make her feel good and change her view of herself and how others viewed her. We also make a chart showing her how her actions could make her mood better or worse: Things that make me feel better Things that make me feel worse Meeting up with friends Looking for things to do with friends (concerts, etc.) Baking Looking at photographs Working on my scrapbook Having a clean apartment Calling Hillary Doing a crafts project Planning a trip Staying in bed Taking long naps Watching too much TV Sitting around (not being productive) Staying on phone with Mom when she’s mad Dwelling on the past Drinking too much Listening to sad songs Then she is more motivated to continue with activity scheduling. Judith: Can I review the four categories again? Self-care, connecting with others, managing at home, and fun. Do you want to pick a category? Maria: Managing better at home, I guess. Judith: Good. What are three things you could do this week that would be meaningful and relatively easy? Maria: I’m not sure. I don’t know if I have the energy to do any more than I’m already doing. Judith: Would you be willing to try some things as an experiment? To see whether you might possibly have more energy than you predict? Maria: Yeah, I guess so. Judith: Okay, so three things that wouldn’t be overly tiring? Maria: I could throw out the newspapers and take the trash out. Judith: Good. What else? Maria: Change the sheets on my bed. Judith: Good. What else? Maria: (Thinks.) Throw out some food from the refrigerator. Judith: All good things. What would it mean if you can do those things? Cognitive Behavior Therapy: Basics and Beyond

Maria: I’m not sure. Judith: Might it mean that you can do things even if you’re tired? That you can start to take control of your life? That you can take steps toward getting a better life? Maria: Yes. I think so. Judith: Can we write some of this down on your Action Plan? Next, Maria and I talk about obstacles that could get in her way or that could interfere with her feeling good about doing these activities. We discuss unhelpful thoughts she might have before, during, and after the activities. We review the importance of giving herself credit and set up a reminder system. We also discuss how she would feel when she accomplished these tasks and what that would signify about herself and her future. Finally, we make this a no-lose proposition: Either she would do the activities or she would keep track of the thoughts or practical problems that got in the way. USING AN ACTIVITY CHART Some clients, like Abe, are likely to follow through with activities they committed to in session without discussing precisely when to do them. Other clients benefit from committing to do certain activities on certain days at certain times. You and the client can collaboratively schedule these activities on their Action Plan or using an Activity Chart (Figure 7.1). Make sure to help clients list their aspirations at the top of the chart to help motivate them. It’s useful for some clients to use the Activity Chart to collaboratively plan an entire day, hour by hour. Clients can use this schedule as a template, making a more specific schedule each morning or previous evening. Make sure that the schedule is on the easy side, especially when clients are more severely depressed. It’s unreasonable to expect that they can go from being almost completely inactive to being active every hour of the day. They may need to schedule periods of relative inactivity interspersed with activities that require more effort. RATING ACTIVITIES When clients use the Activity Chart to schedule activities, they can later use the same chart to circle or check off which of the activities they had actually completed. Some clients are willing to fill in the

Activity Scheduling

Activity Chart with all their activities, prescheduled or not. You’ll collect a lot of important data if clients are willing to rate how much of a sense of pleasure and/or mastery they got from each activity. Or they can just rate their overall mood during the activity on a scale of 0–10. Clients can create scales with their own sample activities at anchor points such as 1, 5, and 10 or 2, 5, and 8. (See Figure 7.2 for two kinds of rating scales.) When people are depressed, their memories are often more negative than their actual experience. They may believe that an entire day or week was bad. Doing ratings immediately after an activity (or at lunch, dinner, and bedtime) helps them recognize the parts that were better. And it allows the two of you to figure out whether they need to schedule more pleasure, mastery, social, or self-care activities—­and whether to decrease other activities. But here’s a caveat. Some clients dislike rating scales. Others may lack the motivation to track their experiences. Make sure clients are highly likely to rate their activities—­if not, it may be better to make the ratings optional. On the other hand, clients who tend to be organized and detail oriented may be willing to keep track of all their activities during the week and rate them. FIGURE 7.2.  Activity Chart, side 2: Rating scales. Activity Chart Rating Scales Name:  Eric L.

  Date:  October 24

  Directions (optional): Use either the top or bottom scale and fill in activities. PLEASURE MASTERY Arguing with partner Thinking about my credit card debt Watching hockey on TV Raking leaves last year Finding out about my promotion Finishing the 5K race OVERALL RATING SCALE Very distressed/depressed When my girlfriend broke up with me Neutral mood Running errands Feeling great Going to a football game Cognitive Behavior Therapy: Basics and Beyond

TYPES OF ACTIVITIES If you don’t know which activities to suggest to clients, you can review their typical day (pp. 121–123). Then ask yourself these questions: “Given my client’s aspirations . . . Which activities is the client doing too much of? Which activities is she doing too little of or avoiding altogether? Does he have a good balance of mastery, pleasure, self-care, and social experiences? What can she do that will be meaningful and lead to positive emotion, connection, and empowerment? What can he do that will help him draw positive conclusions, especially about himself?” Also ask yourself, “Which new activities is the client most likely to engage in?” When relevant, you can suggest that clients search online for pleasurable activities or hobbies or interview other people to find out what they do. When appropriate, you might suggest engaging in some activities with family members, friends, neighbors, or others in the community. In any case, when reviewing their Action Plans in subsequent sessions, make sure to help clients draw conclusions about these experiences and especially what it means about them that they did these things. In the next chapter, you’ll read more about setting and reviewing Action Plans and what to do when clients have difficulty following through with Action Plans. CLINICAL TIPS When Clients Have a Problematic Behavior or Habit Clients who binge eat, smoke, use substances, overspend, gamble, or act angrily or aggressively might record all their activities to investigate patterns of occurrence, or they might just record the occurrence of maladaptive behaviors. USING THE ACTIVITY CHART TO ASSESS PREDICTIONS When clients are skeptical that scheduling activities can help, you can ask them to predict levels of mastery and pleasure and connection,

Activity Scheduling

or what their overall mood will be on an Activity Chart and then record their actual ratings. These comparisons can be a useful source of data. If they find their predictions are inaccurate, they usually become more motivated to continue scheduling activities. If their predictions turn out to be accurate, you’ll ask questions to conceptualize the problem, and then likely do problem solving and respond to unhelpful thinking. Judith: Can we take a look at your predictions on the Activity Chart and what actually happened? Maria: (Nods.) Judith: (Looks at the first chart.) Let’s see . . . It looks as if you predicted very low scores, mostly 0’s and 1’s for the three times you scheduled to meet your friends, but you actually rated your pleasure and sense of connection as 4’s and 5’s. (pause) What do you make of that? Maria: I guess I was wrong. I thought I wouldn’t enjoy myself, but I did, at least some. Judith: What do you think it says about you that you were willing to get together with your friends even though you predicted you wouldn’t have a good time? Maria: I guess it shows I’m willing to give things a try. Judith: Absolutely! That’s such a good sign. (pause) Would you like to schedule more social activities for this coming week? Maria: Yeah. Judith: Good. Do you see what could have happened—­and, in fact, what was happening before you came to therapy? You kept predicting that you’d have a bad time with your friends so you didn’t make any plans. In fact, you turned down their invitations. It sounds as if this Action Plan helped you test your ideas. You found it was wrong that you’d have a bad time, and now it sounds as if you’re more willing to schedule more. Is that right? Maria: Yes. But that reminds me, I wanted to talk about one prediction that actually turned out worse. Judith: Okay, when was that? Maria: I predicted that I’d get a 5 in pleasure when I went to the community garden over the weekend. But I got a 2. Judith: Do you have any idea why? Maria: Not really. Cognitive Behavior Therapy: Basics and Beyond

Judith: How were you feeling when you were at the garden? Maria: Kind of sad. Judith: What was going through your mind? Maria: I don’t know. I mean, going to the garden used to be one of my favorite things to do. But I didn’t enjoy it. I just felt tired. Judith: Did you have thoughts like that—“Going to the garden used to be one of my favorites. I’m not enjoying this. I’m so tired”? Maria: Yeah, I think so. Judith: Anything else go through your mind? Maria: I remembered this time when I went with my ex-­boyfriend. It was soon after we met. I was so hopeful about our relationship. Judith: Did you have a picture in your mind of that occasion? Maria: Yeah. We were walking around, holding hands. I was telling him the names of all the flowers I knew. But he eventually broke up with me. Judith: Okay, let me see if I understand. [summarizing] Here in my office you thought you’d get a moderate sense of pleasure when you went to the garden. But, instead, you got very little. It sounds as if you were thinking of how it used to be and then you had some negative thoughts like “Going to the garden used to be one of my favorites; I’m not enjoying this; I’m so tired.” And you also had an image in your mind of a specific time when you first went there with Roger but then you remembered he broke up with you. And these thoughts and the memory made you feel sad. (pause) Does that sound right? Maria: Yeah. In this last part, I use the Activity Chart to identify automatic thoughts that are undermining Maria’s enjoyment of an activity. Next, we come up with responses to these thoughts and to the memory so she can enjoy the garden more in the future. CLINICAL TIPS When Clients Aren’t in the Moment It’s important for clients to give their full attention to the activity they’re engaged in. If they engage in depressive rumination or obsessive thinking, mindfulness (Chapter 16) can help them let the thoughts come and go as they focus their attention on their immediate experience.

Activity Scheduling

SUMMARY Scheduling activities is essential for most depressed clients. Many clients need a rationale, a reminder of their aspirations, guidance in selecting and scheduling activities, instruction in how to focus their attention fully on the experience (and how to bring their focus back to it when their mind strays), and responses to predicted automatic thoughts that might interfere with initiating activities or gaining a sense of pleasure, mastery, or connection. Therapists often need to be gently persistent in helping clients become more active. Clients who are quite inactive initially benefit from learning how to create and adhere to a daily schedule with increasing degrees of activity. Clients who are skeptical about scheduling activities may benefit from doing behavioral experiments to test their ideas and/or checking the accuracy of their automatic thoughts by comparing their predictions to what actually occurs. REFLECTION QUES TIONS Why is scheduling activities so important for most clients with depression? How might you conceptualize a client’s relative inactivity and lack of mastery or pleasure? PRACTICE EXERCISE Using an Activity Chart, schedule for the coming week some worthwhile activities, in line with your aspirations, that you might have difficulty committing to. Create scales to predict the sense of pleasure, mastery, and/or connection you’ll get from doing each activity. Use the same scales to write your actual ratings after engaging in these activities. Cognitive Behavior Therapy: Basics and Beyond