1 Basic rationale of behavioural activation and other low intensity treatments Tereza Ruzickova Psychopharmacology and Emotion Research Lab University of Oxford 16th March 2023 Introduction Anxiety: "What if this happens?" Me: "But it won't." Anxiety: "But what if it does?" Me: Effective Altruism Lecture plan (some of it might change) 1. Basic rationale of behavioural activation (BA) and other low intensity treatments 2. Understanding BA from the perspective of learning theory and neuroscience 3. The practical methodology of BA and other low-intensity skills 4. Evaluating efficacy and areas of clinical application 5. Implementation and dissemination, challenges and solutions 6. Discussion, Q&A with a Psychological Wellbeing Practitioner from the UK Anonymous feedback form: https://tinyurl.com/sr79zydk Baseline assumptions... • It is useful to conduct experiments on psychotherapy, with the golden standard being randomised controlled trials • It is useful to measure efficacy of psychotherapy with quantitative (as well as qualitative) methods • Cognitive behavioural therapy is one of the most experimentally supported treatments, particularly for common mental health problems, i.e. depression and anxiety (but not the only one!) Mental health problems in the Czech Republic (in 2017) • 22% experienced mental health disorder • 5% mood disorder • 7% anxiety disorder •11% alcohol use disorder • 5% suicide risk Formanek et al. (2019) Formánek, T., Kagstróm, A., Čermákova, P., Csémy, L, Mladá, K., & Winkler, P. (2019). Prevalence of mental disorders and associated disability: Results from the cross-sectional CZEch mental health Study (CZEMS). European psychiatry, 60, 1-6. Mental health problems in the Czech Republic (in 2020) • 30% experienced mental health disorder • 12% mood disorder • 13% anxiety disorder • 10% alcohol use disorder • 12% suicide risk Winkler et al. (2020) Winkler, P., Formanek, T., Mlada, K, Kagstrom, A., Mohrova, Z., Mohr, P., & Csemy, L. (2020). Increase in prevalence of current mental disorders in the context of COVID-19: analysis of repeated nationwide cross-sectional surveys. Epidemiology and psychiatric sciences, 29, e173. Treatment gap in the Czech Republic (in 2017) 60% mood disorders 70% anxiety disorders 90% alcohol use disorders Kagstrom et al. (2019) ... don't receive treatment Kagstrom, A., Alexova, A., Tuskova, E., Csajbók, Z., Schomerus, G., Formanek, T., ... & Čermákova, P. (2019). The treatment gap for mental disorders and associated factors in the Czech Republic. European Psychiatry, 59, 37-43. What do you think are the main barriers to seeking mental health care? Barriers to seeking mental health care • stigma (self & public) • not identifying as having a mental health problem • "my problem is not bad enough" • too expensive (therapist qualification, insurance policies) • too far to travel • too impractical • finding the right fit of therapy type and therapist personality "Mental health care worldwide is at the start of a revolution that will change the shape of health care practice in the next two decades. We are at the birth of a new era—in the development of evidence-based therapies, in the delivery of mental health services, a new era oriented towards the promotion of psychological wellbeing on a community-wide basis." - Oxford guide to low intensity CBT interventions Have you ever heard about low intensity treatments before this lecture? Low intensity mental health treatments = effective treatments that require less time on the side of the specialist, use specialist time in a more cost-effective way (e.g. in a group context) or can be administered by a non-specialist = still require substantial time on the side of the user, but may be accessed more flexibly = significantly reduce financial costs and/or practical burden Possible examples of low intensity treatments? Group therapy Possible examples of low intensity treatments? Group therapy Possible examples of low intensity treatments? Web-based counselling Group therapy Brief school-based Web-based counselling Group therapy Brief school-based Web-based counselling Group therapy Self-help books f Possible examples ( of low intensity V treatments? Brief school-based counselling Peer support Web-based counselling Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based counselling il therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based counselling Email therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Peer support Web-based Mental health apps counselling il therapy Group therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Psychological assistants Peer support Web-based Mental health apps counselling Email therapy Group therapy Therapy through phone calls / texts Self-help books Community therapy by GPs, nurses, teachers, pharmacists? f Possible examples ( of low intensity V treatments? Brief school-based counselling Psychological assistants Web-based counselling Peer support Mental health apps Guided self-help Group therapy Email therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Brief school-based counselling Psychological assistants Community therapy by GPs, nurses, teachers, pharmacists? Web-based counselling Peer support Mental health apps Guided self-help Group therapy Crisis intervention Email therapy Therapy through phone calls / texts Self-help books Possible examples of low intensity treatments? Community therapy by GPs, nurses, teachers, pharmacists? Web-based counselling Brief school-based counselling Psychological assistants Peer support Mental health apps Guided self-help Group therapy Crisis intervention Email therapy Therapist robots?! Therapy through phone calls / texts Possible examples of low intensity treatments? Self-help books Community therapy by GPs, nurses, teachers, pharmacists? Web-based counselling Brief school-based counselling Psychological assistants Peer support Mental health apps Guided self-help Group therapy Crisis intervention Email therapy Therapist robots?! Therapy through phone calls / texts Have you ever used or provided any of these interventions? Self-help books Community therapy by GPs, nurses, teachers, pharmacists? Web-based counselling Brief school-based counselling Psychological assistants Peer support Mental health apps Guided self-help Group therapy Crisis intervention Email therapy Therapist robots?! Brief school-based counselling Therapy through phone calls / texts New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Self-help books Community therapy by GPs, nurses, teachers, pharmacists? Web-based counselling Psychological assistants Peer support Mental health apps New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Higher cost-effectiveness Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments Helping lower income countries New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating Greater choice Higher cost-effectiveness Service flexibility Lower unemployment rate? Increased access Shorter treatments Helping lower income countries New models of health care The development of new services New ways of working and new workforces New ways of training and supervision New ways of engaging the public New ways of communicating World peace? Greater choice Higher cost-effectiveness Service flexibility How have low intensity treatments come about? • Treatment becoming shorter, effective and evidence-based • But not nearly in enough provision to meet demand 1978 - first ever self help book? CBT can be delivered as effectively by mental health nurses (Marks et al., 1985) OVER 1,250,000 Copies Sold in 23 Languages VER MOOD SECOND EDITIO Change How You Feel by Changing the Way You Think Dennis Greenberger, PhD I Christine A. Padesky, PhD SECOND EDITION Over 100,000 in Print! The Clinician's Guide to CBT Using MIND OVER MOOD 'I Christine A. Padesky erger 1995 How have low intensity treatments come about? • Treatment becoming shorter, effective and evidence-based • But not nearly in enough provision to meet demand • Mechanistic research - psychotherapy component studies Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) * Stable negative cognitive schemas about the self, the future and the world * Lead to automatic negative thoughts (interpretations of life events) * Leads to depressive behaviour (avoidance) Jacobson et al. (1996) background * Cognitive model of depression (Beck et al. 1979) * Stable negative cognitive Schemas about the self, the future and the world * Lead to automatic negative thoughts (interpretations of life events) * Leads to depressive behaviour (avoidance) * Cognitive treatment was assumed to be the main ingredient •Rush et al. (1977) * schema: "I am unlovable" ' biased information processing: - pays more attention to signs of rejection - more likely to remember examples of rejection than acceptance automatic negative thought: "He takes too long to text me back because he doesn't really love me. This always happens to me." x CD CO cognitive distortions y/^All or nothings, thinking "If he doesn't text back quickly, he's a bad boyfriend." Disqualifying^N the positive "He never texts me back quickly" Jumping to conclusions 2 + 2 = 5 "ľm sure he wants to break up with me." /" Over- >^ generalizing 'fvtrythtpg >i always rubotsh' nothing y .»*J ever ncfiftffU "This always happens to me with men!" f Labelling \ "I'm such an idiot." Personalization "this is my fault V J "He is probably mad at me because I screwed something up." cognitive therapy • monitoring automatic thoughts that trigger intense feelings • finding more helpful thoughts (second wave of CBT) • cultivating a new relationship towards thoughts (third wave of CBT) Is full cognitive therapy necessary? • How important is the work on negative "cognitive schemas"? • How important is behavioural activation? • How important are coping skills, like assertiveness training? • What about exposure treatment? • What about relaxation exercises? Jacobson et al. (1996) study • Comparing full cognitive therapy (CBT), which included BA, AT and other techniques targeting deeper schemas vs Behavioural activation (BA) only vs Behavioural activation (BA) + Automatic thoughts intervention (AT) Jacobson et al. (1996) study * 152 participants • Scoring at least 20 on Beck Depression Inventory * Random allocation * Four experienced cognitive therapists • Three manuals created (CBT, AT, BA) • 12-20 sessions Jacobson et al. (1996) results • the 3 groups (CBT, BA, BA+AT) were equivalent in depression recovery after the intervention and at 6 month follow up • equivalent effects also found on measures of dysfunctional thinking • despite all therapists expecting full CBT to have the strongest effect (strongest allegiance) THOUGHTS (What we think affects how we feel and act) A \ BEHAVIOUR EMOTIONS (What we do affects (How we feel affects how we think and feel) what we think and do) Hm, behavioural activation seems to work well enough on its own! Wait, Tereza... you haven't actually explained what behavioural activation is! The mechanism of depression onset & maintenance Something difficult happens The mechanism of depression onset & maintenance The mechanism of depression onset & maintenance Something difficult happens Sadness, lack of energy Interrupted routine Anhedonia Lack of motivation The mechanism of depression onset & maintenance The mechanism of depression onset & maintenance The mechanism of depression onset & maintenance Primary cause Something difficult happens 4, Sadness, lack of energy Interrupted routine Anhedonia Lower activity 7» Lack of motivation The mechanism of depression onset & maintenance Primary cause Something difficult happens Sadness, lack of energy Interrupted routine Secondary ^\ » cause ^ Anhedonia Lower activity m~ , ^ A. A. ^ Lack of motivation The mechanism of depression onset & maintenance Primary cause Something difficult happens Sadness, lack of energy Interrupted routine Secondary ^\ » cause ^ Anhedonia Lower activity m~ , ^ A. A. ^ Lack of motivation Primary cause John has recently gone through a breakup. Secondary cause John has become a lot more inactive. The simple power of behavioural activation Behavioural activation • small, measurable steps towards increased activity just above current level • balance of routine, pleasurable and necessary activities • acting before feeling (outside in / action first) • avoiding boom and bust STEP 1 : RECORD WHAT YOU ARE CURRENTLY DOING Use the blank 'My Starting Point Diary' to record what you are currently doing during the week. Start today and record over the next 7 days. There are two boxes each for the morning, afternoon and evening so just try to include the main two things you have done for each. At the end of each day have a look at your diary and write any comments you have in the comments box. Think about what you have been up to, and try to note if there were times when you felt better or worse. This will help you and your PWP when you discuss your week at the next session. It can really help later on if you are able to provide some detail about: 'What' you are doing - i.e. 'watching television' 'Where' you are doing it - i.e. 'lounge' 'Who' you were with - i.e. 'on my own' My Starting Point Diary Monday Tuesday Wednesday Thursday Friday Saturday Sunday Afternoon Morning What Where Who What Where Who What Where Who What Where Who Evening What Where Who What Where Who c S E E 3 Worksheet A : Identifying activities Under each type of activity write down what you want to be able to achieve. Please include all activities you can think of here, regardless of whether you think you can do them or not. We will deal with that in Step 3. Again don't worry if you struggle with this step. Anything you get down will be a bonus as your PWP is always there to help. Routine e.g. cooking, walking the dog, food shopping Pleasurable e.g. going out with friends, reading Necessary e.g. paying bills, taking children to nursery I Worksheet B : Organising activities by how difficult they are Least difficult Medium difficult Youtube: Co můžete teďhned udělat proti depresi? ŕ/utne) M 1 flWffojt/cescrjtfrwrd _ ukliUíf si v pokoji Youtube: Co můžete teď hned udělat proti depresi? __ - m*dLi Hit/r e/a* « UL : / 4* dUe^v^ - 2.pr«vg naučit *t p< ~^ Kr*t na Ústavu - ctol^u mftWl do pnt'U^ r pro^rajmova! Youtube: Co můžete teďhned udělat proti depresi? • /urärr peci > podfat re, mi fOn-úautW' \Mi* Youtube: Co můžete teď hned udělat proti depresi? * př^btím, mí se činí ! PO N 0€LÍ D \Jk\\ v a iU4 pre<< sf>au/hi ČTVRTEK (Mnu*) What activities help you feel better? Richards et al. (2016) study • Randomised controlled non-inferiority trial • Around 450 participants allocated to either BA or CBT (largest trial of BA to date) • No differences found in efficacy but BA significantly more cost-effective • This was driven by lower costs of junior mental health workers who administered BA "Our results, offer hope to many societies, cultures, and communities worldwide, rich and poor, struggling with the effect of depression on the health of their people and economies." Other low intensity interventions? • Problem solving • Worry management - Graded exposure • Sleep management • Motivational interviewing • Physical exercise interventions Problem solving • First outlined by D'Zurilla and Goldfried (1971) • Step-by-stem system to approach and solve problems • Aim to empower patients with skills adopted for the treatment of depression and anxiety across a variety of populations: older adults (Kirkham etal., 2016), veterans (Kasckow, etal., 2014), ethnic minorities (Unlu Ince et al., 2013) and patients with chronic-obstructive pulmonary disease (Lee et al., 2015) and cancer (Hopko et al., 2011) How would you help this client? Problem statement: Over the last few months I have been feeling stressed and overwhelmed due to lots of pressures at work. I have been working long hours to try to help this, but this has meant that I am constantly tired and irritable. I have been seeing much less of my family and spending less quality time with my children. I'm starting to feel depressed and unmotivated. I hardly ever do any relaxing activities.