Clinical Prompt
Step 1. Record & Monitor Weekly Activities
- activity baseline
Step 2. Pleasure & Mastery Activities
- identify pleasure preferences
- rate the sense of enjoyment
- identify mastery preferences
- rate the sense of achievement
Step 3. Schedule Activity Additions
- identify times in baseline where child is typically unproductive and depressed
- add mastery activities [1 per day]
- consider breaking mastery activities into smaller steps
- add pleasure activities [1 per day]
- help set a goal to add a combination of seven new mastery and pleasure items to each new week
- notice and address avoidance activities
Step 4. Prediction Rating
- anticipate
- predict sense of enjoyment &/or mastery
- rate sense of enjoyment &/or mastery
Special Considerations:
- cross out any activity in baseline that is not absolutely essential
- pruning
Forms Charts
Weekly Activity Schedule CBT#12-001
Pleasure Activity List CBT#12-002
Mastery Activity List CBT#12-003
Download Available | CBMT 12 Supplemental Docs
Introduction
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 is 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 the child to higher levels of activity – even though s/he doesn’t feel like it. Aaron Beck (Beck et al. 1979), Arthur Freeman (Freeman et al. 1990), Christine Padesky (Greenberger and Padesky 1995), and others have shown that a technique called activity scheduling can re-energize the child and offer significant help in overcoming depression. The initial steps of the technique involve monitoring and recording daily activities and rating them for levels of pleasure and mastery. The later steps encourage the child to schedule in advance increasing numbers of pleasurable and mastery activities.
Symptom Effectiveness
Several studies by the National Institute of Mental Health have demonstrated the effectiveness of activity scheduling as one component in the cognitive behavioral protocol for depression. Numerous studies have shown that increasing the activity level alone, without any other intervention, can significantly reduce depression.
Time for Mastery
The initial assessment period during which you monitor and record the child’s activities lasts for one week. It will take four to eight weeks thereafter to schedule the gradual increase of pleasure and mastery activities.
Instructions
Step 1: Monitoring and Recording Weekly Activities
Make at least eight photocopies of the Weekly Activity Schedule [CBT#12-001]. Each box on the schedule represents an hour of time. Throughout the next week have the child record his/her main activity or activities during each hour. Whatever s/he is doing, just have him/her write it down. If the child doesn’t have time during the day to keep a record of activities, be sure to have them make a record each evening.
The reason you’re having the child keep detailed accounts of activities is to establish an activity baseline that will help you and the child recognize progress in the weeks ahead. This is the foundation on which the child will build a plan to both mobilize him/herself and help feel less depressed.
Step 2: Identifying and Rating Pleasure and Mastery Activities
While the child is recording the first week’s activities, s/he will need to pay attention to two variables: pleasure and mastery. The first question to ask the child is: ‘Has the activity you’ve written down provided you any pleasure?’ If so, s/he should write a P in that cell and then s/he should rate the pleasurable activity on a scale from 1 (minimal pleasure) to 10 (extreme pleasure).
The child will also need to identify mastery activities. These include those activities in which s/he takes care of him/herself or others. A list of example mastery activities is provided under Step 3. If a cell contains a mastery activity, the child should write an M. Then you should have the child rate the sense of achievement, given how tired or depressed s/he 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 how much the child objectively achieved, nor does it reflect what s/he would have achieved before s/he was depressed. Instead it measures a sense of achievement that takes into account how hard this activity was, considering how s/he was feeling.
Identifying and rating pleasure and mastery activities is very important. It may help the child recognize how his/her life has gotten out of balance; many things s/he formerly enjoyed are probably no longer part of the week. What s/he is now doing probably provides very little emotional nourishment. Pleasure ratings also give information about the activities s/he still enjoys, and which ones offer the best opportunity to boost his/her mood. Noticing and rating mastery activities may help the child recognize that, despite everything, s/he is still trying hard. S/he is still doing things to cope. And even though s/he is not as efficient or effective as s/he was before becoming depressed, the things s/he does are real achievements, given how s/he feels.
Step 3: Scheduling Activities
It’s time to encourage the child to increase both pleasure and mastery activities during the week. Have him/her identify at least ten hours on the activity schedule when s/he is engaged in an optional activity that provides neither pleasure nor a sense of mastery. See if s/he can find one or two of these hours each day. Soon you will have him/her schedule new pleasure or mastery activities for these hours to replace the old, unprofitable activities.
Using the Pleasure Activities List [CBT#12-002] have the child begin to think about and develop a list of his/her own. The Pleasure Activities List is a short list and include both adult and child interests. There are many other possibilities for activities that would bring pleasure. Provide some of your own ideas about pleasurable activities. Have the child think back to the things s/he has enjoyed. Encourage the child to remember everything s/he ever tried that was fun. Review the list above and try to turn some of the generic categories into specific things that give the child pleasure. For instance, under games, s/he might have enjoyed playing relivio, monopoly or cards. Under crafts, s/he might have enjoyed needlepoint or building miniature models. Under artistic activities, s/he might enjoy finger painting or singing. Under calling or visiting friends, there may be certain people that the child would enjoy spending more time with. Have the child fill in all the specific pleasure activities that s/he has enjoyed or can imagine enjoying in the future.
Don’t be surprised if many of the things the child enjoyed in the past seem totally without interest now. Or if things s/he once looked forward to seem more of a hassle or a burden. This is the effect of depression. When s/he begins to schedule pleasurable activities into his/her week, s/he will feel better, even if the activities seem uninteresting at the moment since the very process of scheduling is promising of a potential change.
Have the child select five [05] to seven [07] pleasurable activities [one a day] to schedule on the next week’s activity chart.
At the time you should also try to have him/her add one [01] new mastery activity each day. Often these are self care efforts the child may be neglecting. S/he may need to shop, run errands, clean or straighten something, write letters, or make important calls. When you’re depressed and immobilized, even normal self-maintenance can seem impossibly hard. Thus, you may find that even personal hygiene such as brushing teeth or taking a shower, needs to be scheduled. The Mastery Activities List [CBT#12-003] is a prompt of some activities that the child might schedule into his/her week.
Make a list of mastery activities that might give the child a feeling of accomplishment. Have the child identify all possible mastery activities that might eventually be scheduled into the week. From the list s/he made of possible mastery activities, have him/her select from five [05] to seven [07] to sprinkle through the coming week, in the same fashion as with pleasure activities. Make sure that the child does not do more than one extra mastery activity a day.
Take notice of the hours in the Weekly Activity Schedule where the child has typically been unproductive and depressed. These can be identified by you and the child on the baseline schedule and are prime opportunities to substitute a mastery activity that can give a sense of achievement.
Note that some mastery activities may be too involved to accomplish in an hour, or simply too overwhelming when tackled all at once. It may help to break a mastery activity into smaller steps that can be accomplish in no more than five to fifteen minutes. For example, a plan to improve the appearance of the living room might involve many steps, starting with a decision to buy and hang a new poster. Some mastery activities may stretch over two or more weeks as the child works through each step in the process.
Weeks 3 through X
Have the child set a goal to add a combination of seven mastery and pleasure items to each new 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 the child has been avoiding as a good source of mastery items. If s/he’s been putting off doing homework, have him/her make an appointment with him/herself on the Weekly Activity Schedule to get it done. If s/he’s been putting off renewing friendship, have him/her write in a definite time when s/he will accomplish this task.
The child must make the commitment to pleasure items as equally important as the mastery activities. Right now his/her life is out of balance – there isn’t enough that is genuinely enjoyed. Increasing the number of nourishing experiences in the week is an absolutely essential step to overcoming depression.
Step 4: Prediction Ratings
A very important part of planning activities is trying to anticipate how they will make you feel. Most depressed people make very conservative predictions about the amount of pleasure or achievement they will feel during a planned activity. It’s OK for the child not to feel hopeful. S/he may anticipate very little in the way of good feelings from planned activities. But s/he should do them anyway and evaluate what happens.
Have the child use a blank Weekly Activity Schedule to plan the new mastery and pleasure activities for the coming week. S/he should use the 1-10 scale to predict how much pleasure or achievement s/he will feel, and circle that number on the schedule.
During the week the child should write the actual mastery or pleasure rating for each new activity. This can be placed right next to the circled prediction. One of the things you and the child are likely to notice is that actual pleasure or achievement experiences often feel better than expected. As noted earlier, depression tends to make you pessimistic. Comparing prediction to the actual pleasure or mastery levels experienced may help the child recognize how depression distorts his/her view of things. The fact that the new activities may feel better than anticipated could help the child resist the discouraging inner voice that says, “Don’t bother with anything new; it’s a lot of work and you’ll still feel lousy.”
Special Considerations
Some people believe that they don’t have time in their week for anything new. Since the weekly activity schedule is a crucial intervention for overcoming depression, the child may need to limit or suspend some of the activities that s/he typically does in order to increase the ratio of pleasure and mastery experiences. Have the child go through the Weekly Activity Schedule and cross out any box where the activity isn’t absolutely essential. These are the hours where the child may now substitute new mastery and pleasure activities.
After four or five weeks of adding new activities, nearly everyone will find their days becoming rather full. At this point a certain amount of pruning may be in order – eliminating some of the new activities that offer little nourishment.
Despite the fact that you’ll be adding fewer new activities after weeks 4 or 5, you should still continue to have the child make plans on the Weekly Activity Schedule. Writing something down increases the chance that you will do it. Keep filling in planned mastery and pleasure activities in the weekly schedule until you see a real improvement in the child’s level of depression.