CBT Techniques (2) Behavioural Activation


I love this photo of kite-surfers at a beach near where we live. I've never kite-surfed in my life and I think there's very little chance that I'll start at the age of 61, but I love to watch them leaping and somersaulting over the water. There's something about the way they harness the wind and the waves, defying the forces of nature by taking control of the way it drives them and their kites. It must surely require some bravery too. And they have to hold on very tightly; a bit like I do when I'm in what I call tsunami mode.


The sense of being in control is of course the last thing we feel when we lose someone to suicide. There is no sense that anything in the world is in anyone's control, and the emotional and cognitive chaos that ensues after the bomb blast can be nothing short of terrifying. I find that I have periods when I feel much better and not at all depressed, and I have times when I feel extremely low. The gaps between the low periods are longer now, and the depressive episodes don't last as long as they once did, nevertheless when they hit me I can really struggle to climb out of the black hole.


Behavioural Activation (BA) is part of Cognitive Behaviour Therapy (CBT) and is also a stand-alone treatment for depression. You may not be clinically depressed at this moment, but it can be a really useful tool to have ready for the next time it happens.


CBT uses "formulations". These are just models that try to demonstrate how different elements are contributing to us feeling low, depressed or anxious. I love imagery, and I like models with arrows and boxes that can make what is often a complex and complicated thing look fairly simple. It can untangle a big, messy ball of feelings and give us an understanding of how it works and maybe, just maybe, suggest what we can do to make it a little easier for ourselves.


So, here's my BA Formulation:




The model shows how I can get stuck in a vicious cycle of despair. The ENVIRONMENTAL FACTORS are not changeable; these things have already happened and are outside my control. The LESS REWARDING LIFE I have now is the result of what has happened. Its not my fault, but again I can't easily change it. My FEELINGS about losing Anton and being unable to work are completely understandable and normal, and I have every right to feel this way. Its really only my BEHAVIOURS that I have any direct control over. And its easy to see from my formulation that these behaviours are contributing to my depression.


Its very important to note here that none of these behaviours is wrong. There are times when I really want to look at photos of Anton, and having a glass of wine is definitely a pleasurable activity. Likewise some days I just don't feel like talking to anyone. What's key is that all these things are ok to do when I'm not feeling depressed (and thankfully even if I am a bit low, eating more chocolate is not, on its own going to hurt). But the days when I'm sliding down the black hole are not the days for me to engage in these activities, because they are only going to drag me further down the hole.


Whilst there's emphatically no behaviour or activity that I or anyone can think of that is going to lessen my pain, or make me feel happy, or take away the loss I feel, nevertheless there are behaviours that are more, or less, helpful to me. And given that there's absolutely nothing else I can change about the situation I am in, what can I exert some control over? The only thing I can do is to do something, and hope that it may have a knock on effect on how I'm feeling.


MY TOOLBOX


1. REGULAR ACTIVITIES

If you're working you might not need to organise much by way of regular activities, because you'll have less free time than me. I don't go to work at the moment. This is simply because, at least for the time being, I don't feel able to work with other peoples' problems when I am still trying to cope with all my own emotions. Working as a psychotherapist gave me a lot though, and I really miss it. So I've filled the gap a bit with some regular volunteering, teaching English with a lovely group of people supporting refugees. Its a regular fixture on Thursday mornings. Other regular activities have included Alek and I taking our grandson to swimming lessons once a week and then spending the day with him. During the pandemic my brother and I met to walk and talk once a week on Friday mornings for a year or more, lockdowns permitting. I attend my monthly local TCF group, in person now, but online during lockdowns, and I've recently joined a book group with a friend. A vital element, especially at the beginning, is that all these things can be cancelled if I'm not feeling up to it.


2. OCCASIONAL ACTIVITIES

In the early months I didn't do any of the things I've listed here. I just stumbled through the days, desperate for them to end. But about 5 months after we lost Anton I started doing some volunteering during the pandemic, doing shopping or taking patients to appointments. This was a great way to feel like I was doing something meaningful. It suited me too, because I could choose the tasks I accepted (I found I didn't cope well with calling lonely elderly people to check how they were doing. I was easily overwhelmed when dealing with others' emotions). I also helped out with delivering leaflets for the local Green Party, and through that got involved with packing up donations for Ukraine. I didn't have to tell anyone what I was going through; everyone was kind and friendly and yet slightly impersonal, which suited me fine. I did a couple of online drawing courses with a local artist which were really absorbing and interesting, and I started doing pastel portraits of my friends' children.


I count myself very lucky to have really supportive friends and a wonderful family. Therefore, there is always something booked in my diary to look forward to: meeting a friend for lunch or coffee; going to our neighbours for tea and cake; walking with a friend; and more recently going to a play or show or concert. I invite friends who live away to stay for a couple of days, and I go to see them too; or we meet at a halfway point. I book TCF walks when I can. I try to arrange little trips or days out, somewhere different where Alek and I can walk the dog and enjoy the countryside.


None of these things take away any of the pain, but they provide distraction, give my life some meaning, and help me feel connected to others.


3. LISTS:

I know that if I am more active, if I do something, especially something physical, I feel a little better. If I do some housework, even if its just the washing up, then I get a small sense of achievement. Having done it, I can always go back to sitting ruminating about how awful my life is, or I could do something else.


When we are depressed we tend to only see everything that's wrong; our thinking gets skewed and we can be incapable of noticing any of the good stuff. When I am feeling down, I can't seem to access the part of my brain that keeps lists of all the things I need to get done at some point. All I can think of is how depressed I'm feeling. And if I can think of some task that needs doing, I immediately do not want to do that particular thing. And maybe its a garden thing and its raining outside; or perhaps its something that requires more energy than I have right now.


What really helps me when I'm feeling this way is to keep a list. I write the list when I am having a good day, an energetic day, a sunshine day. The list consists of lots of really basic regular things that need doing, like dead-heading the flowers on the patio, or cleaning the loo, or putting some washing on. It also contains more energetic occasional activities like cleaning the oven, or painting the living room. The great thing about having a fairly long list is that I get to choose what I feel like doing that particular day. My only rule is that I have to do one thing from my list.


You may have noticed that my list seems only to contain chores, and no fun stuff. That's partly because when I'm really low I don't want to do anything fun, and partly because I always have meetings with friends booked in my diary anyway. This particular list is needed when I don't have any other plans and the day stretches out before me like a yawning dark cavern. I know on those days that I need to take myself in hand, and it works for me every time. It just stops me hurtling downwards and gives me something to cling on to. Even if all I do is get some boring chores done, I can feel a little bit proud of myself. And tomorrow is another day...


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