Table Of ContentBrief Behavioural Activation for
Adolescent Depression
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Brief Behavioural
Activation for
Adolescent Depression
A CLINICIAN’S MANUAL AND SESSION-BY-SESSION GUIDE
Laura Pass and Shirley Reynolds
Illustrations by Masha Pimàs
First published in Great Britain in 2021 by Jessica Kingsley Publishers
An Hachette Company
1
Copyright © Shirley Reynolds and Laura Pass 2021
Illustrations copyright © Masha Pimàs 2021
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eISBN 978 1 787 75503 1
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Contents
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Part 1. Introduction
1. Getting Started: How to Use this Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Who is this manual for? 13
What is Brief Behavioural Activation (Brief BA)? 13
Who is Brief BA for? 15
What training and supervision are needed? 15
Want to know more? 21
A note on health and safety 22
Part 2. How to Deliver Brief BA: The Treatment Manual
2. How to Assess Adolescent Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
First steps and introductions 27
How to explain confidentiality and its limits 29
How to assess depression symptoms in young people 31
Methods to assess depression 36
What increases the risk of depression? 37
Getting parents’ perspectives 37
Risk assessment 38
Managing self-harm and suicidality 41
Suitability for Brief BA 47
Introducing Brief BA as a treatment option 48
3. Brief BA Sessions 1 and 2: Getting to Know the Young Person Better . . . . . . . . . . . . . 51
Getting started and fitting it all in 51
How to engage a depressed young person in Brief BA 52
How to set and use an agenda 54
Ongoing risk assessment 54
Psychoeducation: helping the young person understand about depression and the behavioural cycle
of depression 55
The behavioural model of depression: explaining the Brief BA rationale 56
Engaging and working with parents and carers 58
Involving other adults 60
Tracking progress in Brief BA with Routine Outcome Measures (ROMs) 61
Activity monitoring 65
4. Brief BA Session 3: What Matters to the Young Person? . . . . . . . . . . . . . . . . . . . . . 71
What is important to young people? 71
Helping a young person identify their values 72
The difference between goals, activities and values 73
Troubleshooting 74
5. Brief BA Sessions 4 and Beyond: Doing More of What Matters . . . . . . . . . . . . . . . . 75
Moving from values to valued activities 75
Breaking things down, starting small and aiming for success 76
Valued activities in sessions 77
Valued activities outside sessions 79
Between-session work for the therapist and others 80
Troubleshooting 81
Reviewing progress 82
6. Brief BA Session 6 (and Elsewhere When Needed): Scaffolding and Support . . . . . . . . 85
Problem-solving 85
Contracting 86
Managing disagreement 87
When to use these tools 88
7. Brief BA Sessions 7 and Beyond: Keeping Things Going . . . . . . . . . . . . . . . . . . . . 89
Reviewing progress and thinking ahead 89
Building autonomy and independence 90
Relapse prevention 90
8. Ending Therapy and Living a Valued Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Where are we now? 93
Handing over or referring on 93
Endings in therapy 94
Service specifics 95
Part 3. The Theory and Research behind Brief BA (the ‘Why’)
9. The Unique Challenge of Adolescent Depression . . . . . . . . . . . . . . . . . . . . . . . . 101
Understanding depression 101
The key challenges of adolescent depression 102
How does Brief BA help overcome the challenge of adolescent depression? 107
10. Getting to Know the Young Person and Keeping Them Safe . . . . . . . . . . . . . . . . . . 111
Getting to know your client 111
Using Routine Outcome Measures in Brief BA 113
Keeping the young person safe 116
11. Rewards and Reinforcement: The Behavioural Theory of Depression . . . . . . . . . . . . . 119
Behavioural theory 119
Brief BA treatment of adolescent depression 124
Psychoeducation 124
Using positive reinforcement to increase reward and reduce depression symptoms 125
Social learning theory 126
12. Why ‘What Matters to You’ is Important . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
What are values? 129
Why do we focus on values in Brief BA for young people with depression? 129
13. Brief BA Therapeutic Techniques and Strategies . . . . . . . . . . . . . . . . . . . . . . . . . 135
Psychoeducation 135
Goal setting 136
Self-monitoring of mood and activity 136
Healthy habits 137
Contracting 138
Problem-solving 139
14. The Evidence Base for Behavioural Activation for Depression . . . . . . . . . . . . . . . . . 141
Types of Behavioural Activation therapy 141
Evidence-based psychological therapies for young people with depression 142
Identifying evidence-based treatments – the randomized controlled trial (RCT) 143
How well does BA work? 144
Part 4. Brief BA Session Checklists and Worksheets
Brief BA Assessment Checklist 151
Safety Plan 152
Brief BA: Pre-Session 1 Checklist 154
An Information Leaflet for Young People 155
An Information Leaflet for Parents, Carers and Other Adults 158
Brief BA Session 1 Checklist 161
Young Person Brief BA Session 1 Worksheet 162
Parent Brief BA Session 1 Worksheet 171
Brief BA Session 2 Checklist 186
Young Person Brief BA Session 2 Worksheet 187
Parent Brief BA Session 2 Worksheet 190
Brief BA Session 3 Checklist 194
Young Person Brief BA Session 3 Worksheet 195
Parent Brief BA Session 3 Worksheet 200
Brief BA Session 4 Checklist 205
Young Person Brief BA Session 4 Worksheet 206
Parent Brief BA Session 4 Worksheet 209
Brief BA Session 5 Checklist 214
Young Person Brief BA Session 5 Worksheet 215
Parent Brief BA Session 5 Worksheet 218
Brief BA Session 6 Checklist 221
Young Person Brief BA Session 6 Worksheet 222
Parent Brief BA Session 6 Worksheet 226
Brief BA Session 7 Checklist 230
Young Person Brief BA Session 7 Worksheet 231
Parent Brief BA Session 7 Worksheet 233
Brief BA Session 8 Checklist 235
‘Healthy Me’ 236
Young Person Brief BA Session 8 Worksheet 237
Parent Brief BA Session 8 Worksheet 244
Brief BA Review Checklist 251
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Further Reading and Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265
Acknowledgements
This manual has been written with the help of numerous people who have supported us over many
years. The need to develop Brief Behavioural Activation (Brief BA) emerged from our clinical work
with the Child and Adolescent Mental Health team at Berkshire Healthcare NHS Foundation Trust.
It was increasingly obvious that the demand for treatment was greater than services could meet.
We were aware that this was also a challenge faced nationally and across the world, and that many
depressed young people were waiting for months, or even years, for treatment. During that time
their lives were essentially ‘on hold’. We were also aware that when treatment was finally offered,
many young people did not engage well and many failed to complete treatment. Although we both
trained in classic cognitive behaviour therapy (CBT) for depression, this was not always working
as well as we had hoped.
In our careers we have both been lucky enough to learn from many inspirational clinical
psychologists who managed, against the odds, to combine clinical work with research. The scientist
practitioner model of clinical psychology that they modelled so effortlessly is one we have both
strived to follow. Our role models include Professor Paul Gilbert, Professor David Shapiro, Professor
Malcolm Adams, Ms Elin Evans, Professor Cathy Creswell and Dr Lucy Willetts. They patiently and
tolerantly helped us to learn and develop our clinical and research skills. They taught us that learning
never stops and we are never ‘finished’. They helped us face the fears of recording our treatment
sessions and playing them back in supervision. They showed us how to use session-by-session
Routine Outcome Measures (ROMs) and how to learn from the clients we worked with. Most of all,
they helped us to listen and to hear our clients and to never be afraid of not knowing. Many of the
basic therapeutic skills we describe in this manual were learned from and with them.
We were inspired to develop Brief BA by the work of Professor Carl Lejuez and colleagues,
and were fascinated by their model of Behavioural Activation Treatment for Depression (BATD).
This model of treatment was simple, brief and effective, and could be delivered by non-specialist
therapists. Carl was enormously helpful, enthusiastically shared his experience with us, and
encouraged us to adapt BATD specifically for adolescents.
Working within the NHS team at the University of Reading we were delighted to work alongside
a dedicated and skilful clinical team led by Dr Tamsin Marshall and Dr Lucy Willetts. With the
support of this team we developed the treatment with young people who were referred to the clinic.
At this early stage, Dr Hannah Whitney and Dr Gemma Brisco were essential collaborators, and
their expertise helped shape the content and structure of Brief BA.
Since then we have delivered Brief BA in the NHS, in our own university clinic and in schools
across Berkshire. This work would not have been possible without the help and enthusiasm of
many Brief BA therapists and supervisors who have shared their experiences with us and helped us
continually develop to improve Brief BA. We are especially thankful for the input from Jonathan
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