CBT for Depression

Excerpts from Chapter 13 - Getting Mobilized

One of the effects of depression is feeling immobilized. It's hard to push yourself to do normal self-care activities, and pleasure seems all but absent from your life.

Feeling immobilized is not only a symptom of depression-it's a cause. The less you do, the more depressed you feel; and the more depressed you feel, the less you do. It's a negative spiral that maintains withdrawal-and prolongs depression.

The solution is to push yourself to higher levels of activity-even though you don't feel like it. A technique called activity scheduling can re-energize you and offer significant help in overcoming depression. The initial steps of the technique involve monitoring and recording your daily activities and rating them for levels of pleasure and mastery. The later steps encourage you to schedule in advance increasing numbers of pleasurable and mastery activities.

Symptom Effectiveness

Several studies by the NIMH have demonstrated the effectiveness of activity scheduling as one component in the CBT protocol for depression. Numerous studies have shown that increasing your activity level alone, without any other intervention, can significantly reduce depression.

Time For Mastery

The initial assessment period during which you monitor and record your activities lasts for one week. It will take 4-8 weeks thereafter to schedule the gradual increase of pleasure and mastery activities.

Instructions

Step One: Monitoring and Recording Your Weekly Activities

Make a grid with names of the days at the top and hour-long time slots down the side, like this:

	Mon	Tue	Wed	Thu	Fri	Sat	Sun
6-7am
7-8am
8-9am

Be sure to cover the length of your day. You can make 8 or 9 grids in advance to cover the entire length of the program. Throughout the first week, record your main activity or activities during each hour. Whatever you're doing, just write it down.

The reason you're keeping detailed accounts of your activities is to establish an activity baseline that will help you recognize progress in the weeks ahead. This is the foundation on which you will build a plan to both mobilize yourself and help yourself feel less depressed.

Step Two: Identifying And Rating Pleasure and Mastery Activities

While you are recording your first weeks activities, you need to pay attention to two variables: Pleasure and Mastery. First, has the activity you've written down provided you with any pleasure? If so, write a P in the box and rate the pleasurable activity on a scale from 1 (minimal pleasure) to 10 (extreme pleasure).

You also need to identify mastery activities, in which you take care of yourself or others. A sample list of mastery activities is provided under Step Three. If a box contains a mastery activity, write an M. Then rate your sense of achievement, given how tired or depressed you may have felt at the time. The scale goes from 1 (minimal sense of achievement) to 10 (great sense of achievement). Remember that the scale doesn't measure what you objectively achieved, nor does it reflect what you would have achieved before you were depressed. Instead, it measures a sense of achievement that takes into account how hard this activity was, considering how you were feeling.

Identifying and rating pleasurable and mastery activities is very important. It may help you recognize how life has gotten out of balance; many things that you formerly enjoyed are no longer a part of your week. What you are doing now provides very little emotional nourishment. Pleasure ratings also give you information about the activities that you still enjoy, and which ones offer the best boost to your mood. Noticing and rating mastery activities may help you recognize that, despite everything, you're still trying hard. You're still doing things to cope. And even though you're not as efficient or effective as you were before becoming depressed, the things you do are real achievements, given how you feel.

Alicia's first Weekly Activity Schedule: [*Editor's note - We're just posting a day of it; the whole thing would take too long.]

Thursday		Rating
6-7 am	Coffee/read paper	P3
7-8 am	Shower/dress	M2
8-9 am	No makeup/grocery shop	M2
9-10 am	Sit around; crossword puzzles	P2
10-11 am	Reading	P4
11-12 pm	Sandwich at home	M2
1-2 pm	Taking orders (at work)	M3
2-3 pm	Taking orders (at work)	M3
3-4 pm	Taking orders (at work)	M3
4-5 pm	Talking to Rita	P3
5-6 pm	Studying	M3
6-7 pm	Make/eat deinner	M2
7-8 pm	Talk to brother on phone	P3
8-9 pm	Watching TV	P1
9-10 pm	Watching TV	P1
10-11 pm	Watching TV	P1
11-12 pm	Studying	M3

When Alicia reviewed her activity schedule at the end of the week, she made some interesting discoveries. First of all, she was watching a lot of TV and not enjoying it. Most of her pleasure came from interacting with others and sometimes reading. Sitting around the house or sleeping late in the morning seemed associated with increased depression.

Alicia had higher mastery ratings at school when she studied the night before. And while she had some consistent sense of mastery at work, she felt higher levels of achievement when doing a special project. She also felt higher levels of mastery when she made her own dinner and paid some attention to her appearance before going out.

Step Three: Scheduling Activities

It's time to increase both pleasurable and mastery activities during your week. Identify at least 10 hours on your activity schedule when you're engaged in a optional activity that provides neither pleasure nor a sense of mastery. See if you can find 1 or 2 of these hours every day. Soon you will schedule new pleasurable or mastery activities for these hours to replace the old, unprofitable hours.

Examples of Pleasure Activities

• Visiting friends/family,
• phone calls to friends/family,
• movies/plays,
• videos/TV,
• exercise,
• sports activities,
• board or card games,
• internet surfing,
• computer activities,
• internet chat rooms,
• listening to music,
• going away for a weekend,
• planning a vacation,
• hobby activities,
• collecting,
• crafts,
• sunbathing,
• hot bath,
• reading,
• gardening,
• writing,
• going out to eat,
• massage,
• sex,
• picnic, a
• rtistic activities
• ....you get the idea!

This is a short list, and there are many other possibilities for activities that would bring you pleasure. Write 20 (yes 20) of your own ideas for pleasurable activities. Think back over the years to the things you've enjoyed. Attempt to remember everything you've ever tried that was fun. Review the list above and try to turn some of the generic categories into specific things that give you pleasure. For instance, under games, you might enjoy playing pool or cards. Under crafts, you might have enjoyed needlepoint or building miniature models. Right now, list your 20 things that have given you pleasure in the past and that you might enjoy in the future.


Don't be surprised if many of the things of the things you've enjoyed in the past seem totally without interest now. Or if things you once looked forward to seem more of a hassle or a burden. This is the effect of depression. When you begin to schedule pleasurable activities into your week, you will feel better, even if the activities seem uninteresting at the moment.

Right now, select 5-7 pleasurable activities to schedule on the next week's activity chart. At this time, you should also try to add one new mastery activity each day.

Often these are self care efforts that you may have neglected. You may need to go grocery shopping, run errands, clean or straiten something, write letters, or make important phone calls. When you're depressed and immobilized, even normal self-maintenance can seem impossibly hard. The following is a list of mastery activities you might schedule into your week.

Examples of Mastery Activities

• Shopping,
• going to bank,
• helping child with homework,
• supervising children's bedtime,
• bathing,
• preparing hot meal,
• paying bills,
• getting up before 9:00am,
• walking dog,
• fixing something,
• cleaning something,
• doing dishes,
• exercising,
• resolving a conflict,
• doing laundry,
• gardening,
• going to work,
• decorating,
• changing oil in car,
• self help,
• writing in journal,
• calling back friends,
• grooming,
• getting hair cut,
• ...you get the idea!

After reviewing the above list, it's time to make your own list of mastery activities that might give you a sense of accomplishment. Write a list of 20 (yes 20) possible mastery activities you might eventually schedule into your week.


From the list of possible mastery activities, select 5-7 to sprinkle through your coming week. Try not to do more than one extra mastery activity a day-that may be pushing too hard. Notice the hours in your first week's schedule where you have typically been unproductive and depressed. These are prime opportunities for you to substitute a mastery activity that can give you a sense of achievement.

When writing in your activity schedule, try to think of it as an appointment with someone you respect and don't want to disappoint.

Week 3 should look roughly the same as week two. Just 5-7 pleasure activities and 5-7 (extra) mastery activities.

Weeks 3 though X - Set a goal that you will now add a combination of 7 more pleasure and mastery activities to each Weekly Activity Schedule. Try to keep as many of the old items as were pleasurable or practical to repeat. But don't hesitate to drop anything that simply didn't work.

Be particularly aware of things you've been avoiding as a good sense of mastery items. If you've been putting off doing the dishes, make an appointment with yourself on the Weekly Activity Schedule to get it done.

Step Four: Prediction Ratings

When you make your Weekly Activity Schedule, begin predicting the rating of pleasure or accomplishment at the beginning of the week. Alicia's P1 prediction for table tennis indicated that she expected very little enjoyment from this activity. Her P3 prediction for dinner and a movie suggests that expected a modestly good time.

A very important part of planning your activities is trying to anticipate how they will make you feel. It's okay to not feel hopeful. You may anticipate very little in the way of good feelings from your planned activities. But do them and evaluate what happens anyway.

Right now, use a blank Weekly Activity Schedule to plan the new pleasure and mastery activities for your coming week. Use the 1-10 scale to predict how much pleasure or achievement you will feel, and circle that number on your schedule. During the week you should write all your actual ratings next to your circled predictions. One of the things you're likely to notice is that actual pleasure or achievement experiences often feel better than anticipated. As noted earlier, depression tends to make you feel pessimistic. Comparing your prediction to the actual pleasure or mastery that you achieve may help you recognize how depression distorts your view of things.

Special Considerations

Some people feel that they don't have time in their week for anything new. Since the weekly activity schedule is a crucial intervention for overcoming depression, you may need to limit or suspend some of the activities that you typically do in order to increase the ratio of pleasure and mastery experiences. Go through your first Weekly Activity Schedule and cross out any box where the activity isn't absolutely essential. These are the hours where you may now substitute new pleasure and mastery activities