Activity Scheduling

PROBLEM:

To assess, evaluate and improve the activity level of the subject.

BASIC CONCEPT:

Activity Scheduling is a part of behavioral activation in cognitive behavior therapy. It is one of the simplest behavioral interventions in the CBT approach to depression. Depressed people tend to withdraw from ‘everyday life, and this passivity is a safety behavior that itself lowers energy levels, reduces motivation, and confirms in the depressed person the view that they’re best left to their own devices and ought not to bother with others. Severely depressed people often find it hard to do much more than lie in bed all day.

Behavioral Activation:

Behavioral activation (BA) is a therapeutic intervention that is often used to treat depression.

Behavioral activation stems from a behavioral model of depression that conceptualizes depression as a consequence of a lack of positive reinforcement. BA is highly customizable and is a very personal treatment plan.

Behavioral activation (BA) is “a structured, brief psychotherapeutic approach that aims to (a) increase engagement in adaptive activities (which often are those associated with the experience of pleasure or mastery), (b) decrease engagement in activities that maintain depression or increase risk for depression, and (c) solve problems that limit access to reward or that maintain or increase aversive control” (Dimidjian et al., 2011).

The main idea behind BA as a treatment for depression is “to allow patients with depressive symptoms to learn to cope with their negativity” and to “increase positive awareness through the re-development of personal goals in the form of short, medium and long-term life goals” (Chan et al., 2017).

Behavioral Activation involves:

• Understanding the “vicious cycles” of depression
• Monitoring our daily activities
• Identification of goals and values
• Building an upward spiral of motivation and energy through pleasure and mastery
• Activity Scheduling: purposefully scheduling in enjoyable and meaningful activities
• Problem solving around potential barriers to activation
• Reducing avoidance
• Working as a team to make gradual, systematic, sustained progress. Change doesn’t happen over-night!
• Using between-session assignments. Practice changes the brain, little by little!

Behavioral Activation is an evidence-based treatment used to tackle withdrawal from day-to-day activities in a low mood. It works by identifying the activities that we may lack the motivation or interest to do when we are feeling low, or when we find we have little time for ourselves. These activities are then gradually reintroduced to incorporate structure, enjoyment, and a sense of achievement back into our daily lives. There are four steps to Behavioral Activation:

1. STEP ONE Identifying Activities– The first step of Behavioral Activation is to identify activities that you think you’re not doing. These may be things you used to do but no longer find pleasure in, or those that you seem to have little time in your week to do. You can also include activities that you have always wished to do but have never had the motivation to begin. Activities can be broken up into three separate categories; routine, necessary and pleasurable. Evidence shows that in order to have a healthy balance of mood we should include these three main types of activities as part of our weekly routine.

a.Routine Activities– Activities that are done day to day to make our lives more comfortable. Such as washing, housework, preparing food and exercise.

b.Necessary Activities– Activities that are essential and the longer we leave them the worse the negative consequences, Such as; paying bills, applying for jobs, booking medical appointments.

c.Pleasurable Activities– Activities that give a sense of achievement or connectedness to others and improve our quality of life, Such as; seeing friends, hobbies, gardening, sports.

• STEP TWO Ranking Activities– The second step of Behavioral Activation is to rank activities in order of how difficult they would be to carry out currently. Think of which activities would be easiest to do, or most difficult to carry out depending on your mood. Behavioral Activation works best if it is graded, only carry out activities to begin with that you feel are achievable, before moving on to activities that may be more difficult.
• STEP THREE Scheduling Activities– The third step of Behavioral Activation is planning into a diary the activities identified in steps 1 and 2 as many people find when an activity is planned and scheduled it is more likely that they will actually complete it. By planning a range of activities, from all three categories, we gradually reintroduce routine, a sense of achievement and pleasure back into our daily lives.
• STEP FOUR Implementation & Monitoring– The final step of Behavioral Activation is to complete the activities you have planned into your diary. Monitoring your mood while carrying out activities allows you to see the benefits of increasing activity levels. It is important to be flexible and to increase levels of activity week by week. Reviewing the diary on a weekly basis can help us to highlight our achievements and identify and overcome any obstacles.

The next step in Behavioral Activation is determining the behaviors on which to focus to improve our mood. While some behaviors, like exercise and meditation, can be used right away to improve mood directly, many of the behaviors that are likely to help us are those that align with the things that we enjoy or are important to us.

An exploration of “values,” “pleasure,” and “mastery” describe much of the“stuff” that makes life worth living. This process can help us come up with tangible goals to move us toward the things that are most important to us. Goals and objectives outline the steps we take to experience our lives more fully. They give us targets to help us experience more pleasure, mastery, and value-driven behavior.

“Values” are what we find meaningful in life. They are the most important things to us. Everyone has different values, and for each of us they can change over time. They are like a compass, pointing us in the direction we want to go.

“Pleasure” involves activities, or “play” that we enjoy for the sake of the activity itself. Hobbies, games, spending time in nature or spending time with a good friend.

“Mastery” involves activities, such as work or sports, that involve the development of skills; we are able to accomplish things and feel a sense of mastery over our environment. When enjoyed in moderation and diversified well with other activities, they can increase positive emotions and improve how we feel about ourselves. Also, we may feel more creative as we learn to master certain skills, adding to the possibilities of enjoyment.

“Goals and objectives” outline the steps we take to experience our lives more fully. They give us targets to help us experience more pleasure, mastery, and value-driven behavior

Activity Scheduling is a tool for combating passivity and gradually re-engaging the depressed

person in some of the routines of their daily life. At the same time, it allows for the ‘testing’ of

certain depressive assumptions (“I don’t enjoy anything these days…”, “I’m just a useless waste of space…“)

The first step in Activity Scheduling is simply to monitor the activity over the course of a week by recording on a grid. It allows you to take a baseline reading of current activity levels, and the results often hold pleasant surprises in showing the depressed person that they often achieve more than they give themselves credit for. At the same time, it gives an opportunity to set realistic goals to improve mood.

By rating the intensity of the symptom alongside the specific activity, it becomes possible to work out the circumstances that make someone more depressed and identifies those activities that take the edge off depression. By analyzing these patterns, one can gradually introduce more of those activities that are helpful.

Pleasure and mastery events scheduling is a behavioral technique to help clients engage in activities that give them a sense of pleasure and achievement in a structured way. It can be very difficult for clients to simply resume previous levels of activity, so this strategy enables clients to use a weekly timetable in which they can schedule particular activities. It is important for clients to start with activities that are simple and achievable. The depressed person fills out the Activity Schedule by describing what they did (briefly), one word that describes a rate of intensity of mastery (M: 0-5) and pleasure (P: 0-5).

REVIEW OF LITERATURE:

Cuijpers, P., Van Straten, A., & Warmerdam, L. (2007) conducted a meta-analysis of randomized effect studies of activity scheduling. Sixteen studies with 780 subjects were included. The pooled effect size indicating the difference between intervention and control conditions at post-test was 0.87 (95% CI: 0.60~1.15). The changes from post-test to follow-up for activity scheduling were non-significant, indicating that the benefits of the treatments were retained at follow-up.

In a study conducted by Iqbal & Bassett (2008) a quality improvement project was carried out that implemented Activity Scheduling in an inpatient depression group program. Sixteen inpatients completed the Beck Depression Inventory II, and a questionnaire, which was specifically designed to assess the perceived usefulness of AS. In addition, 14 nursing staff completed a similar questionnaire. Both quantitative and qualitative analyses were carried out. Results showed that all participants found AS useful. Eight inpatients had not engaged in any activity prior to being involved in AS. Most inpatients reported gaining some pleasure and satisfaction out of doing AS and experienced a positive effect on their mood and recovery. While 12 staff expressed interest in learning more about AS, 10 needed more information before carrying it out themselves, and only four had the time to do so.

In a study conducted by Gonzalez et.al. (2010), five depressed patients with sub optimally controlled type 2 diabetes were treated with 10–12 sessions of individual cognitive–behavioural therapy for adherence and depression (CBT-AD) in a case-series design. The intervention was delivered in a hospital setting by a collaborative team consisting of a psychologist, a nurse educator, and a dietitian. Post-treatment, all participants demonstrated a decrease in depression severity and demonstrated improvements in diabetes self-care. Four of the five demonstrated improved glycemic control. These preliminary results provide evidence for the acceptability, feasibility, and potential utility of CBT-AD for patients with type 2 diabetes and depression.

Riebe, Fan, Unützer & Vannoy (2012) examined participant records from the Improving Mood Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self reported activity engagement, and depression outcomes. This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Significant positive associations between activity scheduling, self reported engagement in activities at 12 months, and depression outcomes at 12 months was found. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities.

PARTICIPANT’S DETAILS:

Name: Mr. R. B

Age: 18

Gender: Male

Qualification: 11th class

PROCEDURE:

After establishing successful rapport, The Participant was first asked about how they had been and how they were feeling throughout their last week. After a good discussion about their life it was established that they were having a tough time during this lockdown, unable to stay motivated and carry on with so less to do during lockdown. After that the participant was asked about their detailed daily schedule and about the activities they enjoy doing. They were asked to identify and rank the activities they like doing or would want to do if they can. Using all this information by mutual involvement an activity schedule was prepared for the participant and they were instructed to follow this schedule for a week. The participant was well instructed to rate each activity performed out of 5 on the basis of pleasure and mastery principle and maintaining a rating chart for each activity performed. Their mood rating chart was assessed.

Participant’s reflection–

“Honestly speaking, I was quite unsure if would be able to follow the whole timetable since I get bored easily, but nonetheless I followed it. I never actually had anything better to do ever since we were in quarantine. All I did was study, worry, and surf the internet. I followed the schedule; yoga was something I was not good at but as I kept doing it I got a hang of it and found it good. The thing I liked the most was bike riding and sightseeing at night with safety precautions, since lockdown kept me at home. I was actually able to learn the basics of guitar (through youtube), the thing I always wanted to do but I kept stalling. Studying online studies is hard and very uninteresting, but I was able to concentrate while doing self-study. Overall I found this timetable quite helpful, I felt that I didn’t waste anything and whatever I did had a purpose. I will continue learning guitar.”

DISCUSSION:

The subject filled the Activity Monitoring Worksheet for a period of 7 days, 21 from May 18, 2021 to May 24, 2021. Throughout the day has been rated on a scale of 0 to 10 to indicate the subject’s while doing certain activity throughout the day on an hourly basis. The subject started out with an average mood between 5-6 for activities like Project work, Washing utensils, Cleaning washroom, Attending classes, Doing assignment and teaching her sister the subject reported that these activities basically involves a lot of effort and energy and she often feels exhausted afterwards. However, on weekdays, the average mood rating was found to be between 8 and 9 for most activities but activities like practicing singing and spending time with her brother always rated 10 indicating subject is more driven towards pleasurable activities or activities and for value driven activities such as taking care of self through skincare and bathing, cooking food, and talking to family result in good mood in the subject. However, the subject is not very driven towards mastering certain skill like completing assignments, or on certain days, attending classes have not been rated quite high by the subject on more days than not but somehow subject’s entrance prepration always indicated high mood. This could indicate that subject’s lack of interest in certain activities make it hard for her to maintain a good mood, If she focuses a little on how to make certain tasks more interesting by setting rewards and incentives. Upon educating the subject about the long-term benefits of mastering skills and creating reward-based activities may help improve the subject’s mood while they pursue goals and mastery-oriented tasks.

ACTIVITY PLANNING WORKSHEET