Introduction
Behavioural activation (BA) is a treatment for depression that aims to expand an individual’s contact with rewarding experiences (Hershenberg and Goldstein, Reference Hershenberg and Goldstein2019). A meta-analysis (Ekers et al., Reference Ekers, Webster, Van Straten, Cuijpers, Richards and Gilbody2014) supports BA for reducing depressive symptoms, with comparable effect sizes across delivery modes (individual, group, self-help). BA, and specifically Brief Behavioral Activation Treatment for Depression (BATD), is an appealing intervention for in-patient and partial hospital programs, given the high prevalence of depression in these settings. However, to our knowledge, no studies have examined group-delivered BA or BATD in acute psychiatric settings.
Most of the BA protocols for group settings mirror individual treatment manuals. For example, existing group BA protocols are generally structured with weekly sessions with the same group of participants for several weeks. This is very different from the structure of treatment in acute psychiatric settings, where stays are short in duration and the composition of groups changes daily. In addition, patients are often not able to attend groups in a specified sequence.
To address the unique needs of acute psychiatric programs, we developed new group treatment protocols for BATD based on the manual by Lejuez et al. (Reference Lejuez, Hopko, Acierno, Daughters and Pagoto2011). We retained core elements of BATD, including psychoeducation, self-monitoring, values-assessment and activity scheduling. Based on clinical expertise of clinicians working in acute psychiatric settings, we also considered the unique demands of our specific cognitive behavioural therapy (CBT)-based partial hospital program. For example, because individuals attending these groups also attend other CBT-based groups, efforts were made to incorporate BATD within the over-arching CBT model. In developing these protocols, we strove to create a set of groups that could be flexibly implemented in a wide variety of settings. Each group stands alone and is designed to have therapeutic value independent of participation in other group sessions, while also building on possible attendance at previous groups. In addition, these protocols incorporated research findings which recommend emphasizing value-driven activities.
The aim of the current study was to examine the acceptability of group-delivered BATD in a partial hospital program. Specifically, we sought to understand the experiences of group members regarding what they learned, liked and disliked about the group sessions. We used thematic content analysis to extract themes from feedback surveys administered as part of ongoing quality improvement. Based on prior qualitative studies of individual BA (Finning et al., Reference Finning, Richards, Moore, Ekers, McMillan, Farrand, O’Mahen, Watkins, Wright, Fletcher, Rhodes, Woodhouse and Wray2017), we expected patients to find BATD generally helpful. We did not have a priori expectations about which aspects of the group protocol patients would find helpful or unhelpful.
Method
Treatment setting and BATD protocols
We obtained patient feedback on the BATD group protocols at McLean Hospital’s Behavioral Health Partial Hospital Program (BHP).
We developed four distinct 50-minute BATD groups: (1) ‘What is it?’ (offered twice per week), (2) ‘Practice’, (3) ‘Weekend Preparation’ and (4) ‘Weekend Review’. The full group protocols and hand-outs are available upon request from the corresponding author. The ‘What is it?’ group provided an overview of the treatment rationale and components. Additionally, patients identified and planned one value-driven activity. The ‘Practice’ group experientially demonstrated the practice of BATD and taught individuals to set specific, achievable goals, as well as strategies to overcome barriers to activation. The ‘Weekend Preparation’ group provided a brief conceptual overview of BATD and value-driven activity, and taught patients how to monitor activity and pair it with a mood rating. Group leaders also worked with patients to brainstorm patient values and potential ideas to increase activity. During the group, patients scheduled value-driven activity into their weekend schedule. Finally, in the ‘Weekend Review’ group, patients discussed their experiences regarding their scheduled goals from the weekend. Additionally, group leaders reviewed the rationale behind engaging in behaviours despite one’s mood, taught patients how to use data from self-monitoring to plan their next schedule, and reviewed strategies to overcome barriers to activation.
The series of groups could be taken in any order, as each group underscored the basic principles of BA. All patients participating in a BATD group were eligible to participate in the current study. Responses were collected across 23 BATD groups delivered from March to April of 2019 as part of a quality improvement initiative. In total, 130 anonymous responses were obtained. Due the anonymity of survey responses, it is possible that some patients completed the survey more than once.
Data collection was limited to the last few minutes of each group; thus, we were unable to collect demographic and clinical information. Prior research from this partial hospital indicates that the patient population is mostly White (85%) and approximately half female (52%). Most patients present for treatment in the context of a major depressive episode (~75% either in a full episode or partial remission). The most common diagnoses at admission are major depressive disorder (57%), generalized anxiety disorder (42%), social anxiety disorder (35%) and bipolar disorder (25%).
Measures
At the completion of each BATD group, patients were asked to complete a brief survey about their experience consisting of four items: (1) In a few sentences, briefly summarize what you learned in today’s group, (2) What about this group did you find helpful?, (3) What about this group was not helpful? and (4) Is there anything else we can do differently to improve this group moving forward?
Coders
There were three coders. A.T.S. and K.C. were doctoral students in clinical psychology and L.T. was an undergraduate research assistant. A.T.S. is experienced in developing treatment protocols for BA, has conducted research in this area, and is experienced in delivering BATD. K.C. is experienced in delivering BATD. L.T. had no prior experience with BATD.
Analysis plan
Qualitative analysis was conducted using the principles of thematic analysis. All survey responses were coded by A.T.S., K.C. and L.T. A.T.S. and L.T. separately created an initial code list and then collaborated to create the initial codebook. The three coders adapted the codebook from a close read of a subset of ten surveys. Team members then separately used the codebook to analyse the first question of the remaining surveys and to confer about their suggested codes; they repeated this process with question 2 and determined they had identified the full range of relevant codes for questions 3 and 4. The team used the resulting codebook for a portion of the remaining surveys, resolving discrepancies through consensus and then coded all of the remaining surveys. Discrepancies were discussed until consensus was reached. Throughout the coding process, the team adjusted the codebook to reflect emergent data from the patient responses.
Results
Table 1 shows the three over-arching themes in patients’ feedback about the groups: (1) helpful, (2) unhelpful and (3) mixed feedback (lack of consensus). Within each of these themes, responses generally addressed either BATD group content or the implementation/learning methods of said content. Sample quotations for each theme are provided in Table 1.
Table 1. Summary of themes and representative quotations
Discussion
We examined patient perceptions of group-delivered BATD in a partial hospital program. Patients perceived the core elements from the original BATD protocol (Lejuez et al., Reference Lejuez, Hopko and Hopko2001) as helpful, including values-driven activities, activity scheduling and self-monitoring. Consistent with prior qualitative findings from individual BA (Finning et al., Reference Finning, Richards, Moore, Ekers, McMillan, Farrand, O’Mahen, Watkins, Wright, Fletcher, Rhodes, Woodhouse and Wray2017), patients found setting realistic goals helpful. These findings provide preliminary evidence that the adapted protocol sufficiently conveyed critical aspects of BATD to patients.
Subthemes emerged that were not identified in prior qualitative analyses of BA (Finning et al., Reference Finning, Richards, Moore, Ekers, McMillan, Farrand, O’Mahen, Watkins, Wright, Fletcher, Rhodes, Woodhouse and Wray2017). Unique themes included the importance of value-driven activity and understanding that ‘action precedes motivation’. The emphasis on values is unique to BATD, explaining why this theme did not emerge in qualitative reviews of BA protocols (Lejuez et al., Reference Lejuez, Hopko and Hopko2001). These two subthemes were among the most consistently identified helpful concepts on patient surveys. One aspect of our protocol that differed from the published manual was the inclusion of psychoeducation on the CBT model. This was designed to integrate BATD concepts into the overall CBT-dominant framework of the program. Patient feedback supported integrating BATD into a discussion of CBT principles.
Consistent with Finning et al. (Reference Finning, Richards, Moore, Ekers, McMillan, Farrand, O’Mahen, Watkins, Wright, Fletcher, Rhodes, Woodhouse and Wray2017), patients generally reported they found completing worksheets and practising skills helpful. However, some patients in both studies found it aversive to focus on aspects of behaviour that relate to negative mood. It is possible that patients are uncomfortable engaging in exercises that require approaching negative mood. It is also possible that these patients already spend a substantial amount of time engaging with activities associated with negative mood states. It may be beneficial to replace this exercise with practising concrete, change-oriented BATD skills.
Patients also identified that the group format was helpful in learning BATD skills. To our knowledge, there are no prior qualitative studies that have examined patient experiences with BATD in a group format. Patients reported enhanced perceptions of community support, shared experience and self-exploration, even in this setting where group membership was not consistent.
Several patients identified that the groups’ focus on depression as unhelpful. Although three-quarters of patients are admitted within the context of a depressive episode, many do not meet criteria for a current major depressive episode or have co-morbid diagnoses that they identify as more distressing than their depression symptoms. Group leaders might highlight the benefits of BATD for non-depressed patients by emphasizing overlapping symptoms and behaviours across common psychiatric disorders and including examples that extend beyond depression.
With regard to group structure, patients expressed differing opinions about the proportion of group time allocated to lecturing versus group participation. Some patients benefited from listening to group leaders, while others preferred to hear from other group members. This may reflect that patients have different learning styles. A balanced approach is advisable in order to maximize benefits to patients with varied learning styles.
Our study has several limitations. Feedback was collected immediately following each group. While initial patient perceptions are important, it is unclear how perceptions change over a course of treatment. Surveys were short and limited in scope. Interview data would have allowed for richer extraction of themes. Finally, while we provide information on the demographic and clinical composition of the patients in the partial hospitalization program, we did not collect this information for participants who filled out the survey. The lack of demographic data limits our ability to determine the generalizability of these findings to other groups of patients.
Patients in hospital settings receive intensive care for brief periods of time; existing BATD group protocols require regular weekly attendance and thus do not fit well into the hospital model of care. This study suggests that an adapted BATD protocol can provide patients with an understanding of core concepts and clear examples of how to put these skills into practice, even when groups are not attended regularly over a period of weeks. Patient feedback suggests that patients find BATD helpful. BATD groups should continue to emphasize value-driven activity and how these concepts influence motivation.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1352465820000569
Acknowledgements
None.
Financial support
This research received no specific grant from any funding agency, commercial or non-for-profit sectors.
Conflicts of interest
All authors declare they have no conflicts of interest with respect to this publication.
Ethical statements
The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the BABCP and BPS. This research was exempt from IRB approval by McLean Hospital because the data were anonymously collected as part of a quality improvement initiative.
Comments
No Comments have been published for this article.