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Section 3
Behavioral Activation System in Bipolar Disorder

Question 3 | Test | Table of Contents

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in the last section, we discussed the compassionate perspective technique.  There are four steps in the compassionate perspective technique.  The four steps are to foster an understanding of equality through human struggle, to provide the client with a sense of self worth, to qualify the client’s understanding of the concept, and to validate the client. 

In this section, we will discuss initializing Behavioral Activation Therapy, a type of Cognitive Behavior Therapy .  Three steps to initializing Behavioral Activation Therapy are identifying moments of inaction, emphasizing behavior’s contribution to mood, and emphasizing routine. 

As you listen to this section, consider your client.  How might Behavioral Activation Therapy be used in your practice as an intervention to depressive and hypomanic episodes?

David stated to me during a phone call, "On Saturday, Betsy was out all day with girlfriends, leaving me at home with the baby.  On Sunday she spent nearly $300 for ‘Christmas presents’ at a garage sale.  Christmas presents!  It’s April!"  David further reported that Betsy seemed to have boundless energy, sleeping only two or three hours a night before waking up rested and ready. 

David then gave a full description of Betsy’s subsequent manic episode.  David stated, "Then it got worse.  On Monday she decided to open a bakery.  By telephone, she tried to charge over sixteen hundred dollars to my VISA.  She’d have done the same thing again on Tuesday, but the gal she was talking to couldn’t understand her because she was talking so fast."

David then explained that Betsy’s behavior became so erratic that for the next two evenings he stayed home from work to care for the baby.  David stated, "I think that because I was there I was provoking her sexual demands.  Then I noticed a strange smell in the house.  She was hiding in the basement and smoking pot!" 

Think of your Betsy.  Do these manic episodes characterize your client’s behavior?

If so, perhaps Behavioral Activation Therapy can benefit your client.  As you know, this approach focuses not on negative inhibiting and constriction of thoughts that lead to depression or manic behavior, but rather on the specific behavior.  Behavioral Activation Therapy (BAT) perceives depression as a mental conflict in which the client is no longer experiencing sufficient reward to engage in behaviors that previously were rewarding and reinforcing. 

CBT: 3 Steps to Initialize Behavioral Activation Therapy

♦ #1  Identifying Moments of Inaction
One of the first steps in BAT is to help the client identify those specific moments during which they may think of taking some action but fail to do so.  For example, Betsy stated, "Once David was on the phone with a female client of his.  I didn’t bother saying anything about the way they were flirting because it just isn’t worth it.  I should just be happy to have what I’ve got."  Betsy said that this happened five or six months before the baby was born.  In Betsy’s case, I believed that the inertia resulting form a perceived decrease in the cost-benefit of taking action began the onset of her depressed state. 

♦ #2  Emphasizing Behavior’s Contributions to Mood
The next step I implement when using BAT is to place emphasis on the importance of behavior as contributing to mood rather than on the influence of cognition.  By so doing, I hoped to help Betsy identify how external factors affected her mental state.  Specifically, I focused on the relations between Betsy’s behavior and her environment.  After taking a step back, Betsy saw the financial damage that she had done as well as the domestic problems caused by her substance abuse.  However, like many bipolar clients, Betsy was unable to identify how her mental state affected her behaviors. 

Would you agree that this is exactly why Behavioral Activation Therapy (BAT) can benefit clients like Betsy?

♦ #3  Emphasize Routine
The final step in BAT is to emphasize the reestablishment of routine the maintenance of routine.  For Betsy, this included maintaining a routine for daily activities such as eating, working, socializing, and sleeping.  For Betsy, this approach began to help by providing her specific behavioral routines which helped influenced a more balanced mental state

When using Behavioral Activation Therapy, I find it helpful to have clients log their activities and the moods associated with those activities over on week.  Betsy’s husband, David’s help in this task was invaluable.  Through this process, Betsy became increasingly aware that her withdrawal from potentially uncomfortable experiences actually further increases her sense of depression and the accompanying fatigue. 

Likewise, Betsy found that her manic behavior was the result of pent up energy being released in an erratic fury of cyclic episodes.  Clearly, such withdrawal and manic episodes may be rewarded in the short term, but in the long term, it further exacerbates depression and hypomanic episodes. 

In this section, we have discussed initializing Behavioral Activation Therapy.  Three steps to initializing Behavioral Activation Therapy are identifying moments of inaction, emphasizing behavior’s contribution to mood, and emphasizing routine.

In the next section, we will discuss the implementation of Behavioral Activation Therapy. When implementing Behavioral Activation Therapy, three basic steps can be followed.  These are identifying alternative actions, identifying and engaging previously rewarding activities, and fostering the cognition of devaluing thoughts as distractions.

Peer-Reviewed Journal Article References:
Boswell, J. F., Iles, B. R., Gallagher, M. W., & Farchione, T. J. (2017). Behavioral activation strategies in cognitive-behavioral therapy for anxiety disorders. Psychotherapy, 54(3), 231–236.

Boyers, G. B., & Simpson Rowe, L. (2018). Social support and relationship satisfaction in bipolar disorder. Journal of Family Psychology, 32(4), 538–543.

Dejonckheere, E., Mestdagh, M., Houben, M., Erbas, Y., Pe, M., Koval, P., Brose, A., Bastian, B., & Kuppens, P. (2018). The bipolarity of affect and depressive symptoms. Journal of Personality and Social Psychology, 114(2), 323–341.

Dhokia, M., Elander, J., Clements, K., & Gilbert, P. (2020). A randomizedcontrolled pilot trial of an online compassionate mind training intervention to help people with chronic pain avoid analgesic misuse. Psychology of Addictive Behaviors. Advance online publication.

Dodd, A. L., Mansell, W., Morrison, A. P., & Tai, S. (2011). Extreme appraisals of internal states and bipolar symptoms: The Hypomanic Attitudes and Positive Predictions Inventory. Psychological Assessment, 23(3), 635–645.

Hayden, E. P., Bodkins, M., Brenner, C., Shekhar, A., Nurnberger, J. I., Jr., O'Donnell, B., & Hetrick, W. P. (2008). A multimethod investigation of the Behavioral Activation System in bipolar disorder. Journal of Abnormal Psychology, 117(1), 164–170.

What are three steps to initializing Be
havioral Activation Therapy? To select and enter your answer go to Test.

Section 4
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