Behavioral Activation Therapy, BAT
Here’s a version of BAT, followed by a more formal Manual. The instructions below are simplified
because our patients’ difficulties are usually complex and their “self-efficacy” (ability to change their
own behavior, and belief in that ability) is often very low. They’ll usually need to start simple and small.
Page and pdf numbers below refer to the Manual found at
http://web.utk.edu/~dhopko/BATDmanual.pdf . Pull that up now for reference as you read on here.
When you’ve read the following simplified guide, then read the Manual from Unit 5 (page 266; pdf page
12) to the end, including the Appendices. You’ll see it’s considerably more complicated than the version
here. Some of your clients may be able to handle some parts of the more complex version. Knowing
both versions will give you a better understanding of the method. One more simple version is described
in a 30-minute video: http://impact-uw.org/training/onlinetraining.html , very worth it (including an
important, amusing comment by Dr. Unutzer at minute 21).
First, a simple approach:
A. Get at least some buy-in for treatment. E.g. after listening well to their struggles, try something like:
“You have some really serious problems. You’ve been struggling for a long time. It probably seems
overwhelming, the idea of even trying to change the way things are. Your mood/anxiety problems have
made it difficult to do much of anything, especially things that you might get some real enjoyment from.
But if you want to give it a try, I’ll work hard to help you, and we’ll make the steps really small, at least at
first.”
If she is not ready (this should be apparent very early) shift gears to Motivational Interviewing* mode:
elicit the story of the struggle slowly and well, and listen for the wish for things to be different,
reinforcing that. Stay in listening mode until there’s room to “hand back the bouquet” of reasons for
change that you heard.
B. Once you have a willing client, move through the following steps at her pace. Some clients will go
fast, some will go very slowly, e.g. one of the steps below per week or even slower. The key is to have
success early; you can go faster/farther later. Keep a file for each client with copies of their worksheets.
Give them a folder in which to keep their copy. If they “fail” a step, consider that your mistake: didn’t
make the plan clear enough, small enough, or get full agreement – something like that. This takes
pressure off the client who’ll easily regard not following through as his own personal moral failure.
Step 1: Make a list of activities you’d like to pursue. We’re looking for 10-15 of them. Brainstorm first;
rank-ordering comes later. Worksheets: Appendix A in the manual (page 280, pdf page 26); or if you
need an even simpler breakdown, with even more choices, consider this list of pleasurable activities:
http://elishagoldstein.com/assets/183-pleasurable-activities-to-choose-from.pdf
Step 2: Rank the 10-15 activities from Step 1 by difficulty. Worksheets: Activity Ranking Sheet, page 270
(pdf page 16); or http://psychology.tools/activity-selection.html
Step 3: Starting with the easiest on that list: is it too easy -- will this be a challenge at all? Or is it too
hard – how likely is it that she will be able to actually get this done, in the coming week? E.g. rate how
likely on a scale of 1-10 where 0 is “no way” and 10 is “positive”. She needs to rank it 7 or higher. If even
the simplest behavior is not likely to happen, then break that behavior down into smaller pieces. Find a
simple step where she begins to be almost offended: “sure, I can do that.” Start there or one step
higher.
Step 4: Make a plan for him to actually do this behavior in the coming week. When and where will it
happen? What day, what time of day? If he’s ready for more than just the one behavior, consider a
second, and at most a third behavior. Use Initial Activity Planning Sheet (S drive, PCPC, Teaching) to
determine what day(s), what times of day the behavior will occur. Ask: “what’s going to get in the way
of this actually happening?” and brainstorm work-arounds for barriers.
Step 5: Return visit, or f/u phone call. How did the plan go? What got in the way? “Failure” is therapist’s
error for not structuring activity properly; just need to return to plan and break it down smaller, or
brainstorm other routes around barriers.
If “success”, next step: use the Initial Activity Planning Sheet and add additional activities, moving up
their Activity Ranking Sheet. Go slowly enough to make sure of “success” again. Reinforce continuing
the first successful behavior.
Step 6: Make a plan to continue multiple activities. Use the Task Planning and Achievement Record
http://www.self-help.tools/assets/worksheets/Task_Planning_And_Achievement_Record.pdf (which is
less complicated than but analogous to Figures 7 and 8 in the Manual).
Charting Progress
By week 2, certainly by week 3, if client is successfully underway, create an Activity Level Graph (pg 277,
pdf page 23, Figure 10). Also obtain PHQ-9 and GAD-7 scores at least every other week and enter in
EPIC Documentation Flowsheet.
*Motivational Interviewing review:
http://integratedcare-nw.org/webinars/motivinterview_050610.html
Slides for that webinar:
http://uwaims.org/files/slides/Dunn-MotivInterv-Slides.pdf