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Behavioral Methods I 6

Improving Mood, Increasing

Energy, Completing Tasks, and

Solving Problems

Low energy, decreased interest in or enjoyment of

activities, and difficulty completing tasks or solving

problems are common complaints of people with depression. Not

engaging in potentially pleasurable or rewarding activities

often results in an aggravation of symptoms. A vicious cycle

can ensue in which an individual’s reduced involvement in

pleasurable or productive activities is followed by a further

lack of interest or enjoyment, low mood (feelings of sadness

and despair), increased helplessness, or worthlessness. This

reaction, in turn, may lead to the individual’s further

disengagement in pleasurable or rewarding activities and a

subsequent worsening of depressive symptoms. Eventually, a

downward spiral may continue to occur until the individual

may assume that he is incapable of experiencing pleasure,

completing tasks, or solving problems. Patients with the

deepest levels of depression may become abjectly hopeless and

give up on any attempts to change.

Cognitive-behavioral methods for treating depression and

other psychiatric disorders include specific interventions

designed to reverse patterns of diminishing activity levels,

energy depletion, worsening anhedonia, and reduced abilities

to complete tasks. In this chapter, we discuss and illustrate

some of the most useful behavioral interventions for helping

people with these types of difficulties. Although the

techniques described here are most often used in treatment of

depression, they also can be applied successfully in

cognitive-behavior therapy (CBT) for other conditions, such

as anxiety disorders, eating disorders, and personality

disorders (see Chapter 10, “Treating Chronic, Severe, or

Complex Disorders”).

When implementing behavioral procedures, it is important to

remember the principle that engaging in pleasurable or

rewarding activities is likely to be associated with improved

mood and sense of accomplishment. Likewise, modifications in

negative automatic thoughts or schemas can help promote

adaptive behavior. Thus, behavioral methods are used in

concert with cognitive techniques as an overall strategy for

reaching treatment goals. The examples in this chapter

illustrate how behavioral and cognitive interventions often

augment each other and how therapists can blend these

techniques in clinical practice.

The term behavioral activation can be used to describe any

method designed to reenergize patients and help them make

positive changes. These methods can range from simple one- or

two-step behavioral action plans, to activity scheduling, to

fully developed graded-task procedures.

Behavioral Action Plans

A practical and doable behavioral action plan can engage

the patient in a process of positive change and instill a

sense of hope. The therapist helps the patient to choose one

or two specific activities that could lead to an improvement

in mood and then assists with working out a realistic plan to

carry out this activity. Behavioral activation is often used

in the first few sessions before more detailed cognitive-

behavioral analysis or more complex interventions can be

performed (e.g., activity schedules, cognitive

restructuring). However, we also have found that this

technique can be applied at other stages of therapy when a

simple, targeted behavioral action plan can be used with

significant benefit. The following example shows how this

method can be used to rapidly engage patients in productive

activities very early in therapy.

Case Example

Meredith is a 30-year-old woman, in her sixth month of

pregnancy, who is experiencing depression. Her symptoms

have been at a moderate level of severity since the

second month of pregnancy, when she began to experience

depression. Her first and only previous depressive

episode occurred when she was in school at a community

college. She took sertraline and received some

supportive counseling at that time. The medication

seemed to help, but she doesn’t want to take medication

now because of her pregnancy.

She is a server in an upscale restaurant and hopes to

keep working as long as possible. Her associate degree

is in information technology, but she hasn’t been able

to find employment in that field. She currently lives

alone, and her family lives near her home. Although she

has not received much support from her mother, who is

also depressed, her older brother, who is married and

has two children, is very supportive. She also has two

close friends—one friend from her childhood and another

from work. Her pregnancy was unplanned, but she always

wanted to have a family. She has positive feelings about

the baby, but she is often self-critical because she

does not expect that she will be a good mother. She also

criticizes herself for eating “junk food” and not

maintaining a healthy diet. Meredith wants to stay

friends with her baby’s father, for the sake of the

child, but doesn’t want to rekindle a romantic

relationship.

Meredith reports no other psychiatric history except

as previously noted. She has had no suicidal ideation or

suicidal behavior. There are no physical illnesses, and

her pregnancy has gone well other than her experience of

some back pain, heartburn, and decreased energy.

In Video 12, Meredith and Dr. Wichmann, a psychiatry

resident, focus on some ways to help Meredith become more

active again. Near the end of this second session, they

develop a promising behavioral action plan (Figure 6–1). The

small section of dialogue shown below will give you an idea

of how Dr. Wichmann shaped this intervention. We suggest you

take time now to view the video so you can see how to build a

specific plan that has a good chance of success.

Figure 6–1. Meredith’s behavioral action plan.

Video 12. Behavioral Action Plan: Dr. Wichmann and

Meredith (3:34)

Dr. Wichmann: If you could do one thing this week that could help

make you feel better, what do you think that might be?

Meredith: I think I want to eat healthy.

Dr. Wichmann: When you say that you want to eat healthy, can you tell

me what you mean by that?

Meredith: I want to completely cut out fast food. I want to have more

set meals, and I just want to eat healthy food.

Dr. Wichmann: All of those ideas you named are very important…. I

just wonder if all of those things that you named can be a lot

to take on at once. Do you think there are some smaller, more

specific goals that you could work on … toward that?

Meredith: I think I at least need to go to the grocery.

Dr. Wichmann: OK. Has that been something you haven’t been doing?

Meredith: No, not lately. I’ve been just grabbing food at work or

going for fast food on the way home.

Dr. Wichmann: Well, going to the grocery, I think, is a more doable

goal and something that you can hopefully work toward more

easily than just eating healthy all at once. What are some

possible barriers or obstacles that could make it difficult for

you to get to the grocery?

Because Meredith was moderately depressed and was having

difficulty engaging in any activities that gave her a sense

of well-being or pleasure, Dr. Wichmann was careful to avoid

a behavioral action plan that would be too challenging or

would be unlikely to be accomplished. In this case, Meredith

chose some actions that she thought would be helpful, but Dr.

Wichmann suggested she plan a less ambitious activity. There

were several other strategies used to increase the likelihood

that Meredith would be able to complete the action plan.

These included asking her about potential obstacles or

barriers to completing the plan and then engaging her in

problem solving to address these obstacles. Also, Dr.

Wichmann urged the patient to identify a specific day and

time to complete the activity. Finally, Dr. Wichmann wrote

the behavioral action plan on a card to serve as a reminder

to carry out the plan. Dr. Wichmann and Meredith collaborated

well in developing the behavioral action plan. Note that Dr.

Wichmann asked Meredith for suggestions based on her previous

experiences, rather than simply telling Meredith what to do.

When patients seek treatment, they are usually interested

in making changes. They want to start moving in a positive

direction, and they are looking for guidance for steps that

they can begin to take. Therefore, when the therapist

suggests taking an immediate behavioral action (even if it is

rudimentary) during the initial sessions, this request is

usually greeted by patients as a sign that they will be able

to work together with the therapist on making bigger gains

and on solving larger problems. Behavioral action plans

don’t use fancy or complicated techniques, but they can help

patients start to break out of patterns of withdrawal or

inactivity and show them that progress can be made. This type

of intervention may also be used to good effect in later

stages of therapy or in the maintenance phase of treatment of

chronic conditions. The suggestions listed in Table 6–1 may

help you implement effective behavioral action plans.

Table 6–1. Tips for using behavioral action plans

1. Develop a collaborative relationship before trying behavioral

activation. Don’t put the cart before the horse. Without good

collaboration between patient and therapist, attempts to implement

behavioral action plans may fail. Part of the reason the patient may

carry out the task is that he wants to work with you and can

understand the reasons for making changes.

2. Let the patient decide. Although you can help guide the patient to

actions that may be helpful, whenever possible, ask him to make

suggestions to develop an action plan and then offer the patient some

choices for implementing the plan.

3. Judge the patient’s readiness to change. Before suggesting

behavioral action plans, gauge the patient’s motivation and openness

for taking this step. If the patient is not interested in doing things

differently right now or is not ready to take action, defer the

intervention. On the other hand, if the patient is open to start

moving in a positive direction, capitalize on the moment.

4. Prepare the patient for behavioral activation. Lead up to the

assignment with Socratic questions or other cognitive-behavior therapy

interventions that pave the way for change. Try to ask questions that

educate the patient about the benefits of taking action or that tap

into motivations for doing things differently. One of the best

questions is “How would this change make you feel?” If the answer is

positive and the action stands a reasonable chance of being effective,

the patient will be more likely to follow through.

5. Design assignments that are manageable. Choose behavioral

activation exercises that match the patient’s energy level and

capacity to change. Check out the details of the behavioral plan to be

sure that it offers enough challenge but doesn’t overload the

patient. If needed, do brief coaching on ways to make the plan work

out well.

6. Facilitate the implementation of the action plan. Ask the patient

to identify a specific date and time to complete the activity.

Identify and address any barriers to doing the activity and, if any

are present, assist the patient in addressing these obstacles. Always

write the assignment down as a reminder to do the assignment.

Activity Scheduling

When fatigue and anhedonia progress to the point that

patients feel exhausted and believe that they can experience

little or no pleasure, they may benefit from activity

scheduling. This systematic behavioral method is frequently

used in CBT to reactivate people and help them find ways to

improve their interest in life. Activity scheduling is most

often used with patients who have moderate to severe

depression. However, it can also have a place in the

treatment of other patients who have difficulty organizing

their days or engaging in productive activities. Activity

scheduling focuses on activity assessment and increasing

mastery and pleasurable activities. These methods, introduced

in Juliana’s case below, are described further following the

case example.

Case Example

Juliana had severe depression and was a good candidate

for activity scheduling. She was a 22-year-old, single

Puerto Rican woman who had suffered the loss of her

brother in a car accident a year before she started

treatment with CBT. After her brother’s death, Juliana

dropped out of college to return home to comfort her

parents. However, her own grief was intense and

unrelenting. She was unable to make herself go back to

school the following semester. Her parents understood

Juliana’s grief and did not force her to resume college

or get a job. Juliana’s friends tried to be supportive

for many months after her brother’s death. But when she

consistently rejected offers to go out to dinner and

stopped returning phone calls, her friends eventually

began to drift away.

Juliana was well cared for by her family. There was no

real need for her to work, so no demands were placed on

her. After about a year, her parents thought that

Juliana had overcome much of the sadness from the loss

of her brother. Yet there had been a distinct change in

her behavior. She had developed a more serious demeanor,

a preference for solitude, and a greater tendency toward

introspection. Juliana’s parents felt comfortable

leaving her at home when they were at work or traveling

out of town, because she appeared to be better. However,

one evening her mother came home early from work and

found Juliana preparing to hang herself in her closet.

After a brief hospitalization and initiation of

pharmacotherapy, Juliana improved to the point that she

could be referred to a cognitive-behavior therapist for

outpatient treatment. Given the severity of her

symptoms, one of the first treatment initiatives was to

increase Juliana’s activities so that she could benefit

from the support of friends, feel better about her

personal appearance, practice her social skills, and in

general feel more like her old self. The intervention

began with an assessment of her current level of

activity, experiences that gave her pleasure, and the

amount of mastery she felt over her world.

Activity Assessment

Because depressed patients tend to underreport positive

experiences, emphasize negative perceptions, and focus more

on failures than on successes, self-reports may not be as

accurate as a log of activities kept for a day or a week

between therapy sessions. The activity assessment, or

activity monitoring, also may be used for noting patterns in

engaging in pleasurable or rewarding activities and

corresponding changes in mood. Patients who recognize the

association between specific types of activities and their

mood may be more likely to engage in additional activities to

improve their mood and decrease the severity of their

depression.

The activity schedule form presented in Figure 6–2 can be

assigned as homework but should be started during the session

to ensure that the patient understands the rationale for

activity scheduling and to practice how to use the form.

Beginning with the day of the therapy session, ask the

patient to fill in her activities for each time block before

the treatment session. Encourage her to write in the

activities that actually occurred, no matter how mundane. For

example, activities might include bathing, dressing, eating,

traveling, talking with others on the phone or in person,

watching television, and sleeping. If the patient has

pronounced loss of energy or significant problems

concentrating, it may be best to ask her to complete the

schedule for only 1 day, or a part of a day. Inpatient

applications of activity scheduling often employ a daily

activity schedule instead of a weekly activity schedule

(Wright et al. 1993).

Figure 6–2. Weekly activity schedule form.

Note. This form is also available in a larger format at

https://www.appi.org/wright.

To determine the impact of activities listed on a weekly or

daily schedule, ask the patient to rate the degree of

enjoyment experienced for each, as well as the sense of

mastery or accomplishment that was associated with the

activity. A scale of either 0–5 or 0–10 can be used (Beck

et al. 1979, 1995; Wright et al. 2014). On a 0–10 scale, a

rating of 0 on mastery suggests that the activity provided no

experience of accomplishment, whereas a rating of 10

indicates a great sense of accomplishment. When coaching

patients to use both of these rating scales, it is often

helpful to ask them for specific examples of activities that

correspond to no pleasure/accomplishment, moderate pleasure/

accomplishment, and a great deal of pleasure/accomplishment.

Some patients will give a low rating to simple tasks such as

washing dishes or making themselves a cup of coffee because

they do not consider those activities to be meaningful. When

this underestimation occurs, help them try to recognize the

value of participating in everyday activities. Another

strategy that is often used when rating specific activities

is to have patients rate their mood level, using a 0–10

scale, while engaging in each activity or at the end of each

day. This mood rating helps patients to become more aware of

how specific activities are associated with changes in their

mood.

Patients should try to give themselves credit for small

accomplishments, because progress is generally made in small,

incremental steps. Some simple tasks might receive high

ratings for mastery. For example, after a patient has been

immobilized by depression for some time, making breakfast can

be a big feat and therefore might receive a rating of 8 or 9.

Juliana’s activity monitoring example is presented in Figure

6–3. For her, returning phone calls was an important

accomplishment, since she had managed to avoid them for

several months. Therefore, when she was able to make some

calls, she gave herself a mastery rating of 8 on a 0–10

scale. In the past, Juliana would have rated returning phone

calls only 4 for mastery because it took so little effort.

Figure 6–3. Juliana’s activity schedule.

When symptoms of depression are moderate to severe, low

ratings of pleasure should be expected for two reasons: 1)

there is usually little involvement in activities that most

people would consider highly pleasurable, and 2) the capacity

for experiencing joy or pleasure is usually blunted. If an

event that would normally make the patient laugh or smile

elicits no more than an intellectual understanding that the

stimulus was amusing, this event is likely to be given a low

rating for pleasure. When this phenomenon occurs, it may be

beneficial to develop more realistic expectations for feeling

pleasure until the depression has improved. As an alternative

to feeling disappointed with events and rating them 0,

encourage the patient to at least give a low rating of 1–3

if any pleasant or positive feelings were experienced.

In completing the activity schedule, Juliana gave having dinner

with her parents a rating of only 1 for pleasure. When questioned

about what elements of dinner she had enjoyed, she listed the comfort

of being with her mother, the mashed potatoes with butter, and the

banana pudding—a childhood favorite—she had had for dessert. When

queried about why three different enjoyable things resulted in a

rating of only 1 for pleasure, she reconsidered the rating and raised

it to a 4. It was hard for her not to be conscious of her brother’s

absence during family meals, and thinking about his loss usually

lowered her mood. But when she gave more consideration to the

positive parts of the meal, it seemed more enjoyable overall. With

this in mind, Juliana re-rated some of the other activities on her

schedule and raised their pleasure ratings accordingly.

The questions in Table 6–2 are designed to help patients

evaluate and change their activity levels to increase

pleasurable or rewarding activities and improve mood. When

reviewing the activity schedule form with patients, it is

important to take a collaborative approach and use the

questions in Table 6–2 to assist patients in reaching their

own conclusions about the role of pleasurable and rewarding

activities and to encourage them to make suggestions for

changing their behavior.

Table 6–2. Activity monitoring

Are there distinct periods of time when the patient experiences pleasure

or a sense of accomplishment?

What kinds of activities seem to give the patient pleasure or a sense of

accomplishment?

Are these pleasurable or rewarding activities associated with changes in

mood?

Can these pleasurable or rewarding activities be repeated or scheduled

on other days?

Are there certain times of day or specific activities that appear to be

low on mastery or pleasure?

Are these times of the day associated with low mood?

What can be done to improve activity patterns during those times of day?

Do the ratings tend to be higher for activities that involve other

people? If so, can social contact be increased?

What kinds of activities did the patient do previously that provided

pleasure or a sense of mastery that have been stopped or reduced? Are

there opportunities for rekindling interest in these activities?

Are there any types of activities (e.g., exercise, music, spiritual

involvement, art, crafts, reading, volunteer work, cooking) that the

patient is ignoring but may interest her? Is she open to considering

adding new or different activities to her weekly schedule?

When reviewing the activity monitoring form she completed, Juliana

discovered that there was a pattern of greatest pleasure when she was

involved in activities outside the house or when she made an attempt

to connect with friends (such as making phone calls). She gave one of

her highest ratings for pleasure when walking her dog. In contrast,

she noted that the lowest pleasure ratings were given when she was

home alone with nothing to do. Because her involvement in productive

activities had fallen to such a low level, she observed that her

ratings of mastery were usually minimal. When reviewing the mastery

ratings, Juliana complained that her life had no meaning. She had

limited household responsibilities, was no longer in school, did not

have a job, had lost touch with many of her friends, and had no clear

prospects for becoming more involved in life. Thus she needed to find

activities or commitments that would give her a sense of purpose and

fulfillment.

In Video 13, Meredith and Dr. Wichmann reviewed an activity

monitoring task during their third session. Meredith had

completed her planned trip to the grocery (see Video 12) and

recorded this activity and ratings on the activity schedule.

When reviewing the form during the session, Meredith observed

that she had felt a sense of mastery and pleasure from this

activity and she was surprised by how good the activity made

her feel. Although she found it somewhat challenging to go to

the grocery store, her mood clearly improved after doing so.

Meredith and Dr. Wichmann also reviewed other patterns of

engaging in pleasurable activities and how they influenced

her mood ratings. Finally, Dr. Wichmann asked Meredith if she

had thought about engaging in any new activities.

Video 13. Activity Scheduling: Dr. Wichmann and

Meredith (9:32)

Increasing Mastery and Pleasure

If you and the patient have determined that there are

deficits in experiences of mastery or pleasure in the course

of day-to-day life, you can help make improvements by

assisting the patient to schedule activities between sessions

that will make him feel good about himself. Begin by asking

the patient to generate a list of pleasurable activities,

based on his previous experiences. The patient may also want

to include activities from the monitoring exercise that had

the highest ratings of pleasure. Then you may brainstorm with

the patient to list some new activities that may be worth

trying (see the questions in Table 6–2).

Some patients may have difficulty identifying pleasurable

activities even after reviewing the activity schedule or when

asked about their prior experiences. For these patients, it

may be helpful to review a list of potentially pleasurable

activities using a questionnaire, such as the Pleasant Events

Schedule (MacPhillamy and Lewinsohn 1982; available at:

www.healthnetsolutions.com/dsp/PleasantEventsSchedule.pdf).

Once the patient has identified some of these activities,

then the patient and therapist collaboratively determine

which of these activities to add to the daily routine.

Next, use the activity monitoring exercise to help the

patient determine the types of activities that seem to

produce feelings of mastery. For example, Juliana’s activity

schedule (see Figure 6–3) shows higher mastery scores when

she was responsible for making her own dinner and when she

did her own chores. Using guided discovery, you can assist

the patient in recognizing that continuing current activities

that are high on mastery, or modifying current activities,

may increase their value to the patient and improve mood. If

the patient has completed a goal list, efforts toward

reaching any of the stated goals can be added to the activity

schedule.

After completing the schedule, elicit the patient’s

expectations for success in changing his level of activity

and the likelihood of engaging in the activity. Ask about any

barriers or obstacles that may affect the patient’s ability

to follow the activity schedule as planned. Then work with

the patient to devise a strategy for overcoming these

obstacles. Armed with this information, assign the new

schedule for the following week and ask the patient to rate

each event for mastery and pleasure. Review the plan at the

next session and modify it as needed. Usually activity

scheduling is used in the early parts of therapy and can be

discontinued when the patient is able to initiate pleasurable

and achievement-oriented activities spontaneously. However,

we sometimes use activity scheduling later in therapy when

there are persistent problems with anhedonia, organizing

effective behavioral plans, or procrastination.

Working With Difficulties in Activity Scheduling

Case Example

Charles is a 75-year-old man who lost his wife to cancer

when he was 63. Life was great before his wife died.

They traveled a lot together, took cruises, and went to

movies and the theater. Charles had a good deal of grief

after his wife died, but he rallied and threw himself

into his work as a sales manager for an auto dealer. He

still misses his wife greatly, but he was able to move

on after her death without falling into a deep

depression.

He has a history of one previous depression in his 40s

when he lost his job as a manager in the auto industry.

At that time, he went to a primary care doctor and was

prescribed an antidepressant that was effective for

relieving his depression. Then he found a job as a car

salesman. He continued to sell cars but reduced his work

hours until age 73, when he retired fully because he was

having trouble being on his feet at the dealership.

Arthritis in his knees and feet were giving him much

pain after an hour or two of work.

After retiring, Charles began to slide into

depression. Most of his friends were coworkers at the

dealership. He kept in contact with them for a few

months, but then felt that he was just an “old guy”

and was getting in their way. So he stopped visiting the

dealership or going out with them after they finished

work as he had done in the past. His energy slipped, and

he pulled back from a host of previously satisfying

activities, including woodworking and watching movies.

About once a month, he used to drive 4 hours to his

son’s house for a long weekend, but he stopped doing

that. Other behavior changes included not eating

regularly or well and not preparing food (he used to

bake and cook for family and friends). Charles also has

backed away from socializing with others. He thinks it

is too much trouble to go, so he has refused

invitations.

Charles had been asked to do a homework assignment by his

therapist, Dr. Chapman. The assignment was to monitor and

record his activities for 1 day using an activity schedule.

They had also talked about some positive activities such as

going out to dinner with a friend or doing some woodworking.

In Video 14, Dr. Chapman reviews the activity schedule that

Charles had recorded for 1 day. Although there were pleasure

ratings for the activities, there were no mastery ratings.

When Charles was asked about the difficulty in completing the

mastery ratings, Charles indicated that he didn’t “see the

point” of rating activities such as eating a meal, which

involved little sense of mastery.

Overall, Charles seemed to be stuck in his low activity

pattern and unimpressed with the value of activity scheduling

in making any differences. Thus, Dr. Chapman introduced a

decisional balance worksheet (Figure 6–4) that included the

costs and benefits of engaging in additional activities as

well as not engaging in any new activities (or not changing

behavior). Using guided discovery, he assisted Charles in

completing this worksheet.

Figure 6–4. Charles’s decisional balance worksheet.

After completing the exercise, Dr. Chapman asked Charles

for his conclusions about the benefits and the cons of making

changes in his behavior. Charles saw the benefits of changing

his behavior and decided that he would contact a friend next

week. He also agreed to complete the activity schedule,

including mastery and pleasure ratings, for 1 day as a

homework assignment. Watching the next video will help you

troubleshoot problems in using activity schedules.

Video 14. Difficulty Completing an Activity

Schedule: Dr. Chapman and Charles (8:03)

Troubleshooting Guide 3 includes some guidelines and

suggestions for responding to homework noncompletion. When

addressing problems with completing homework, it is important

that the therapist be nonjudgmental and not blame or label

the patient for being “noncompliant.” It is more helpful

for the therapist to be supportive, understanding, and

empathic when discussing homework assignments, as well as to

take a collaborative, problem-solving approach by following

some or all of the guidelines described in Troubleshooting

Guide 3.

Troubleshooting Guide 3

Difficulties Completing Homework

Assignments

1. Patient doesn’t understand the rationale for

homework. Take time to explain the value of homework

again. Clarify misunderstandings. Give examples of how

others have used homework to their benefit.

2. Patient doesn’t think that homework is helpful.

Check out the patient’s reactions to your assignments.

Are they seen as meaningful, yet doable? If you aren’t

suggesting assignments that are viewed as helpful, step

back and rethink your treatment plan. Also, be sure to

check homework from previous sessions at each subsequent

session. If you don’t do so, patients will conclude

that you do not think that homework is very important.

3. The homework assignment didn’t seem feasible to the

patient. Be careful in assigning too much reading, an

entire week of an activity schedule, or a effortful task

to a patient with deep depression and limited energy.

Recalibrate homework assignments so they are realistic

and consistent with the patient’s abilities,

motivation, and situational factors.

4. Patient didn’t fully understand the assignment,

forgot parts of it, or had difficulty concentrating on

the activity. Was the assignment specific and clearly

stated? Is the patient keeping a notebook or other

record of assignments? Because patients with depression

may have problems with concentration and comprehension,

ask for feedback about their understanding. Ask for the

main take-home points at the end of sessions. And ask

patients to repeat the steps they have planned to do for

homework. Use memory aids such as sticky notes, prompts

from mobile devices, or daily schedules to assist

patients with remembering and completing homework.

5. Likelihood of completing the homework was not

assessed. If you suggest a homework exercise that the

patient is unlikely to do, the chances of success have

been compromised from the start. When assigning or

reassigning homework, assess the likelihood that the

patient will actually complete the assignment: 80%? 10%?

If the patient indicates that she is unlikely to

complete the assignment, troubleshoot reasons for the

low estimate and/or generate alternative homework.

6. Patient has negative thoughts about homework in

general or the specific assignment. Most adult

patients will not have negative reactions to use of the

word homework. They will understand that you are

suggesting practical exercises that can help them cope

better with their problems. However, alternative terms

for homework may be useful when treating patients who

are of school age or who have a negative view of their

school experiences. You can call the assignment an

action plan or a self-help exercise. Also, be sure to

emphasize collaboration in generating assignments so

patients don’t think that they are being told to do

things. When patients contribute to the design of

homework assignments, they may be more likely to

complete them. Specific homework tasks should be

suggested by the patient as often as possible.

Examples of maladaptive thoughts about homework

include “I was never any good in school…. I can’t do

this”; “I have to do the homework perfectly or not at

all”; “I can’t do anything right …. why should I

try?” When you identify these types of reactions to

homework assignments, you can work to modify the

cognitions with thought records, examining the evidence,

or other CBT methods.

Another useful strategy is to normalize homework

noncompletion. Discuss how commonly people have such

problems, and explain that you aren’t expecting

perfection in doing assignments. State that if

difficulties are encountered, you will understand and

will help the patient use the experience as a learning

opportunity.

7. Obstacles such as busy schedules, lack of family

support, or situational stressors repeatedly derail

patient from doing homework exercises. You may need to

spend more time troubleshooting ways to overcome

obstacles. Could you sharpen the focus on goals that are

more realistic or achievable? Could you look for

activities that are less likely to be affected by these

obstacles? Could the patient enlist support of friends

or others to follow through with exercises? If these

actions don’t offer much help, remember that you can do

homework in sessions. You can use cognitive-behavioral

rehearsal to spot obstacles that could be overcome and

build skills for completing the exercises.

8. Patient has a long-standing pattern of

procrastination and difficulty completing tasks. If

procrastination is a chronic problem, you can apply core

CBT methods to help the patient become more active and

productive. For example, elicit and attempt to modify

cognitions associated with procrastinating behavior

(e.g., “I’ll mess it up anyway, so why try…. It will

be too hard…. I’ve tried before and not succeeded….

Everyone else has their act together”). Assess basic

behaviors such as organization of daily activities and

scheduling. Then assist the patient with organizing

realistic plans to complete homework exercises. Use

homework exercises as opportunities to alter

procrastination habits. For example, coach the patient

on the step-by-step methods for graded task assignments

discussed in the next section of this chapter.

Learning Exercise 6–1. Activity Scheduling

1. Complete at least 1 day of an activity schedule for

your own life. Review the ratings of mastery and

pleasure.

2. Practice introducing an activity schedule in a role-

play exercise with a colleague.

3. Use activity scheduling in your clinical practice.

Graded Task Assignments

Graded task assignment (GTA) is a method for making

overwhelming, unmanageable, or complex tasks more feasible by

breaking them down into smaller and more easily accomplished

tasks. GTA can be used in conjunction with activity

scheduling to increase mastery experiences and is

particularly helpful when patients have fallen behind on

chores (e.g., household maintenance or yard work), when they

have put off difficult tasks that have looming deadlines

(e.g., paying bills or filing taxes), or when goals they wish

to accomplish are complicated and require lengthy efforts

(e.g., getting in shape, earning a General Educational

Development [GED] certificate or college degree, filing for

divorce). If the perceived magnitude or complexity of the

tasks has kept patients from taking action, GTA may be the

answer.

Begin GTA by eliciting patients’ perceptions of the tasks

that require attention. Listen for negative automatic

thoughts and evaluate their validity before beginning GTA.

Catastrophic thoughts and black-and-white thinking can

interfere with initiative. Ask patients to write down their

modified thoughts and to review this cognitive analysis

before initiating behavioral exercises. Suggest that they

hold on to this written record as a handy reminder in case

negative thoughts return. An example from the treatment of

Robert illustrates the value of eliciting automatic thoughts

about taking behavioral actions.

Case Example

Therapist: When you think about filing your taxes, what goes

through your mind?

Robert: I go blank. I don’t know where to start.

Therapist: Take a moment and imagine yourself at home and

seeing a commercial for a tax service on television. What

would you be thinking?

Robert: I feel this tightness in my throat. I want to change

the channel.

Therapist: Change the channel because you imagine what?

Robert: I know I have to file my taxes. I didn’t turn them in

last year, and I know the IRS [Internal Revenue Service]

is going to go after me if I turn in this year’s report.

I don’t know how to get started. I don’t have the forms.

I can’t ask anyone else to help because I would have to

tell them that I never filed taxes last year. That would

be too embarrassing. It’s all too much for me right now.

Therapist: So when you are reminded that you have to file your

taxes, you get pretty upset.

Robert: You got that right.

Therapist: And when you get upset, what happens to your

motivation to begin working on the taxes?

Robert: I don’t want to deal with it. I put it off for another

day.

Therapist: If you thought you had the ability to handle the

stress of doing the taxes, would you want to start

tackling the problem?

Robert: I have to do something about it.

Therapist: What would happen if we could find a way to make it

easier for you?

Robert: If it were easier, I think I might be able to handle

it. But it’s not easy.

Therapist: I think I know a way to help.

Robert was overwhelmed by the thought of filing taxes, partly

because he was uncertain where to begin. He had also made a number

of assumptions about the reactions others would have if he asked

for help. The therapist started working with Robert by modifying

the belief that he couldn’t ask for help. When this was

accomplished, they were able to break the task down into smaller

parts and make a schedule for their completion.

The behavioral component of GTA involves listing the

specific components of a larger task and then placing them in

a logical order. Because there are usually many ways to

tackle an uncompleted task, it often helps to discuss several

possible approaches before creating a specific action plan.

Robert thought it might be best to begin by finding someone to help

him with his taxes. His sister, Celeste, thought it would be better

for Robert to organize his materials and collect the proper tax forms

before asking someone for help. His mother, Brenda, suggested he

start by calling the IRS to find out if it would be better to turn in

last year’s tax return first or work on the one for this year. After

discussing these options with his therapist, Robert decided to follow

his first inclination and ask for assistance. He was so overwhelmed

with the task, he did not think he could initiate things on his own.

So he decided to ask Celeste for help as his first step.

The remaining steps involved finding the materials he had at home,

organizing them, downloading the appropriate form from the IRS Web

site, scheduling time with Celeste to begin filling out the forms,

completing the forms, and calling the IRS to discuss last year’s

taxes. Because he wasn’t certain about the order of the steps and

thought it was possible that there were other things he needed to do,

Robert asked Celeste for advice about the order of the remaining

tasks and for suggestions about any other steps that might be needed.

When patients report on their progress at subsequent

therapy sessions, you should praise their efforts and inquire

about how their actions made them feel about themselves.

Reinforce the cognitive-behavioral model, explaining once

again that positive changes in action will help improve mood,

strengthen self-esteem, and create optimism about future

efforts. Ask about their motivation to take on the next step,

and elicit and modify negative thoughts if necessary. After

the first few items from the GTA have been assigned, some

patients may feel enough momentum building to follow through

with the other tasks without assistance from the therapist.

Others will require continued coaching from the therapist to

maintain progress. As energy and motivation levels return to

normal, GTA may no longer be needed to initiate activity.

There will be times when GTA is not successful. A common

reason is that the steps are too complicated for the patient

to accomplish or require more energy than the patient

possesses. In these cases, such tasks may be broken down into

smaller subtasks. You will need to match the complexity or

scope of the subtask to the energy level and the time

available to the patient. Another common reason that GTA

fails is that the person is flooded with negative automatic

thoughts that discourage or interfere with his taking action.

When tasks are difficult, initial attempts to carry them out

may be less than completely successful. The person who is

prone to black-and-white thinking may not give herself credit

for progress made toward a goal. Instead, partial success is

viewed as failure. When designing a GTA intervention, caution

should be taken to keep each step within the capacity of the

patient. When in doubt, it is better to make a task too easy

to accomplish than too difficult.

To learn more about how to implement GTAs, watch Video 15,

an engaging scene from Dr. Chapman’s treatment of Charles.

Despite many attempts and good intentions, Charles has not

been able to get back to work in his woodshop—a pursuit that

previously gave him great satisfaction. He is overwhelmed by

the condition of the shop and has been stalled in efforts to

make objects such as toys for a grandchild, a previous

homework assignment. In this video, you’ll see how to

effectively blend cognitive and behavioral methods to

construct a GTA that works.

Video 15. Developing a Graded Task Assignment: Dr.

Chapman and Charles (7:43)

Behavioral Rehearsal

Any behavioral plan that you want the patient to complete

outside therapy can be rehearsed or practiced first during a

treatment session to 1) assess the patient’s understanding

of the rationale for the plan, 2) check on the patient’s

ability and motivation to carry out the activity, 3) practice

behavioral skills, 4) provide feedback on the skills, 5)

identify and address potential roadblocks, and 6) coach the

patient on ways to ensure that the plan will have a positive

outcome.

Behavioral rehearsal has many applications in CBT. For

example, you might practice breathing training for reducing

anxiety, exposure protocols for overcoming panic and

avoidance, or strategies for stopping compulsive rituals (see

Chapter 7, “Behavioral Methods II: Reducing Anxiety and

Breaking Patterns of Avoidance”). Behaviors that may enhance

adherence to medication regimens (e.g., using effective

communication with the prescribing physician, organizing a

complex medication regimen, implementing a reminder system)

also could be rehearsed in a treatment session. Other

opportunities for using behavioral rehearsal might include

role-playing a plan worked out in a problem-solving exercise

(see Learning Exercise 6–2 below) or practicing skills for

managing social anxiety (e.g., how to make small talk).

Learning Exercise 6–2. Task Completion

1. In a role-playing exercise with a colleague, target a

challenging or difficult task.

2. First practice using the GTA method to work out a plan

to complete the task.

3. Then use behavioral rehearsal to build skills or spot

potential problems in carrying out the plan.

4. Role-play another behavioral rehearsal exercise.

Problem Solving

When people have difficulties solving their problems, it

may be partly due to either a performance deficit or a skill

deficit. Those with performance deficits possess adequate

problem-solving skills but—due to depression, anxiety,

extreme stress, or feelings of helplessness—have difficulty

accessing and utilizing those skills. In contrast, people

with skill deficits may be unable to analyze the nature of a

problem and cannot seem to come up with reasonable ideas to

solve it. Individuals with skill deficits often have had

trouble solving problems in many different areas of their

lives or have repeatedly chosen solutions that have failed or

made matters worse. People with performance deficits can be

helped by identifying and modifying, whenever possible, the

factors that keep them from using their existing skills.

However, patients with skill deficits may require basic

training in problem-resolution methods.

Working With Problem-Solving Performance Deficits

Some of the more common factors that interfere with

effective problem solving are listed in Table 6–3. This list

includes obstacles that may be associated with the symptoms

of a mental or physical illness. For example, depression

often impairs concentration and interferes with the cognitive

functioning needed to solve problems. Other roadblocks occur

when patients do not have the resources to properly address

their problems (e.g., financial, intellectual, or physical

limitations) or when they search for ideal or perfect

solutions when such standards are not attainable.

Table 6–3. Obstacles to effective problem solving

Cognitive impairment Poor concentration, slowed thinking, impaired

decision making

Emotional overload Feeling overwhelmed, dysphoric, anxious

Cognitive

distortions

Negative automatic thoughts, cognitive errors

(e.g., catastrophizing, all-or-nothing thinking,

magnification), hopelessness, self-criticism

Avoidance Procrastination, forgetfulness

Social factors Contradictory advice from others, criticism, lack

of support

Practical problems Insufficient time, limited resources, problem

being beyond control

Strategy factors Trying to find the perfect solution, looking for

one overall solution that will solve several