What is it?

Cognitive behavioural therapy (CBT) is well established as an effective treatment for a range of disorders (e.g., anxiety, affective disorders) (see Nathan & Gorman, 1998). As the name suggests, CBT utilises a combination of behavioural and cognitive techniques to target a patient's symptoms. The focus is on teaching patient's how to control their symptoms, correct faulty thinking patterns and manage their own disorder. Ideally, at the end of treatment, patients should be able to use the strategies they have been taught to deal with any future problems and possible return of symptoms. The content of CBT should be determined according to need and the duration should be time limited.

Summary of the components of CBT detailed in this document

1. Cognitive interventions	Cognitive therapy
2. Behavioural interventions	Behaviour modification
	Exposure techniques
	Activity scheduling

Does it work?

There are a number of studies demonstrating that CBT is effective for a variety of disorders (e.g., depression, anxiety, schizophrenia, eating disorders) (see Enright, 1997 for a review). Further, in randomised placebo controlled trials, CBT has been found to be of comparable effectiveness to appropriate drug therapy (Andrews, 1993). The effects of CBT have also been found to be relatively long lasting. Treatment gains have been maintained at one-year follow-up (e.g., Ladouceur, 2000) and beyond (e.g., Fava et al., 2001)

How do you do it?

The techniques outlined below are designed to be used in collaboration with the patient. See below for an explanation of the main techniques and how to do them.

References and recommended reading:

1. Andrews, G. (1993). The essential psychotherapies. British Journal of Psychiatry, 162, 447-51.
2. Enright, S. J. (1997). Fortnightly review: Cognitive behaviour therapy-clinical applications. British Medical Journal, 314, 1811-1816.
3. Fava, G.A., Bartolucci, G., Rafanelli, C., Mangelli, L. (2001) Cognitive-behavioral management of patients with bipolar disorder who relapsed while on lithium prophylaxis. Journal of Clinical Psychiatry, 62(7), 556-9.
4. Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, E., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioural treatment for generalised anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.
5. Nathan, P. E., Gorman, J. M. (Eds.). (1998). A guide to treatments that work. New York: Oxford University Press.

Cognitive therapy

What is it?

Beck (1979) describes cognitive therapy as 'an active, directive, time-limited, structured approach used to treat a variety of psychiatric disorders (for example, depression, anxiety, phobias, pain problems, etc)' (p. 3). Cognitive therapy is based on the idea that the way a person interprets or appraises a situation is based his or her past experiences, and this focus influences how he or she thinks and subsequently feels. When a person feels threatened they selectively pay attention to what they fear and so are limited in their ability to evaluate the whole situation rationally. The idea behind cognitive therapy is that modifying the way a person thinks, will change the way he or she will interpret a situation, which should lead to a subsequent change in behaviour. For example, a person with depression will often have a number of negative thoughts, which is a classic 'cognitive symptom'. Although treating some of the symptoms of depression using behavioural techniques (e.g., activity scheduling) will be effective, it is also important to focus on this cognitive symptom directly.

The A-B-C model developed by Ellis (1975) is often used to explain the influence of the way we think, on the way we feel and behave.

It is commonly assumed that A leads directly to C. However, in most cases, it is a person's reaction or thoughts in response to an event, B, that influences how he or she feels. Consider the following example.

Mary presents for a medical certificate saying she fears going to work. She recently began a new job. She has looked forward to starting her new role for some time and is keen to make a good impression on her colleagues. Mary goes out of her way to be friendly toward everyone but finds that her new colleagues do not make the same effort and sometimes even ignore her. This makes Mary feel like she is worthless and that there must be something wrong with her. To make matters worse her boss is very inpatient and yells at her for no reason. Mary loses her motivation to go to work and starts to think that she must be 'boring', that people think she is stupid,(Further enquiry makes it clear that she feels they think incompetent and not worth bothering with. Mary starts to feel down and gets quite anxious before going to work.xxxadd D&E steps

Clearly, this was an unpleasant event for Mary to experience when she started her new job. While, it is not unreasonable to feel upset by her boss and colleagues reactions, Mary's reaction went beyond this.

Referring back to the ABC model for Mary:
A = Activating event = being ignored by colleagues and boss yelling at her.
B = Belief or reaction to A = Mary says to herself that she is boring, stupid, incompetent and not worth bothering with.
C = Emotional consequences = feeling very down, upset, and anxious.

As illustrated above, our beliefs and what we say to ourselves (i.e., 'self-talk'), have a very strong influence on how we feel. Thus, the aim of cognitive therapy is to teach patients how to modify their beliefs (B) about an event, in order to change their emotional reaction (C).

The next stage, often referred to as D in this model, is where the patient learns to 'challenge' their negative thoughts and substitute in more rational beliefs. The end result is E, a new emotional effect or consequence.

To summarise:

Does it work?

Cognitive therapy has been found to be an effective component of treatment for a variety of disorders. For example, cognitive therapy is at least as effective as drugs in the treatment of unipolar depression (e.g., Hollon, Shelton & Loosen, 1991), panic disorder (e.g., Clark, et al., 1994), and generalised anxiety disorder (Power et al, 1990). Further, patients who receive cognitive therapy are also less likely to relapse following treatment termination (Teasdale et al., 2001)

How do you do it?

Typically, cognitive therapy is not used alone but in conjunction with other techniques. These techniques will be guided according to the disorder that is being treated (e.g., when treating anxiety, exposure may be used concurrently) and cognitive therapy should be tailored accordingly. Cognitive therapy consists of several key components and specific techniques are available to guide therapy. These are presented below in a simplified form, but is recommended that the reader refer to the primary texts to gain a full understanding. It is also important to note that this form of treatment is best provided by a clinician specifically trained in this style of therapy, and the following guide should be supplemented by specialist training

Key components of cognitive therapy

1. Explain the A-B-C model
2. Identify and elicit negative automatic thoughts (NAT's) and dysfunctional beliefs
3. Test these NAT's by generating and assessing the evidence for and against
4. Challenge NAT's and dysfunctional beliefs
5. Generate more rational and realistic counter-statements

1. Explain the rationale behind cognitive therapy and use the A-B-C model to guide your explanation.
   
   
2. One term that is referred to frequently in cognitive therapy is 'negative automatic thought' (NAT). As the name implies, these are negative thoughts, occurring automatically in response to a situation or event. These thoughts can occur either consciously or unconsciously. NAT's are often the focus of cognitive therapy because they are strongly believed by the person and these thoughts exert a powerful influence on behaviour and interpretations of events. For example, a man who reports anxiety when speaking in public may report the NAT that 'everyone will think he is stupid', which leads him to avoid such situations. A depressed woman might typically report the NAT 'everyone hates me' and so withdraw from the people around her.
   
   
3. It is useful to ask the patient to monitor his or her thoughts is relation to certain situations which occur over the coming week. This can be done in a format similar to the example below.
   

   Example of thought monitoring form

   DATE

   EMOTION(S) What do you feel? How bad is it (0-100)?

   SITUATION What were you doing or thinking?

   AUTOMATIC THOUGHTS What exactly were your thoughts? How far do you believe each of them? (0-100%)

   
   
4. When the patient returns with examples of their thoughts from the previous week(s) you can start to work together to test the evidence for and against the thoughts. The aim of this process is not to tell the patient what to think, but to work collaboratively and teach the patient how to challenge their thoughts in a more realistic manner. You can start off by eliciting more details about the reported situations and asking the patient to report what thoughts were going through their head at the time.
   
   
5. It is important to determine at this stage whether the thoughts the patient is reporting are rational or whether the thoughts are irrational, and reflect some of the common thinking errors. These thinking errors include:
   
   
   • All or none thinking: some people see things in black or white categories. This means that they usually see things as being only one extreme or the other - black or white - no shades of grey. For example, 'I used to be so confident, but now I am hopeless at everything'.
     
     
   • Overgeneralization: people who engage in this style of thinking tend to draw conclusions on the basis of one or more isolated events, and then apply this to other related and unrelated areas of their life. For example, if someone fails a test they might think, 'I am hopeless at everything I do'.
     
     
   • Selective abstraction (filtering): this happens when a person focuses on a specific detail of an event and takes this out of context. The person will tend to ignore other important features of the situation and make unwarranted conclusions. For example, when the person is talking to someone they might notice them glance away momentarily and conclude, 'they think I'm boring'.
     
   • Discounting or disqualifying the positive: some people tend to reject successful experiences or positive events by generating a reason why it does not count. For example, if someone manages to catch a train all the way to work, they might discount the event by saying, 'it wasn't full today, so it didn't count'
     
     
   • Jumping to conclusions: sometimes people tend to draw a conclusion even when there are no facts to support it. A good example, is when people 'mind read' or think they know what another person is thinking. For example, they might think 'my friend thinks I'm not worth bothering with', even though the friend has not said this.
     
     
   • Magnification or minimization: this is when people assign too much or too little importance to an event. For example, a person who makes one mistake in a test might think, 'this is a total disaster, I'm going to fail my course and get kicked out of the university'.
     
     
   • Personalisaton: this occurs when a person blames things on themselves when there is no reason for taking part or all of the blame. For example, 'I always bring bad luck'.

   It can be useful to point these errors out to the patient to make them more aware of when they are being unrealistic.
   

6. As discussed, you need to start working with the patient to generate evidence for thoughts. This can be done by asking a series of questions. You can start by generating evidence for the thought being true and then look at the evidence against the thought being true. This can be done by asking, 'what is the evidence for the thought being true?' and 'what is the evidence against this thought being true?'. It is useful to do this in a quite a structured manner and to write it down when you first attempt this technique with the patient.
   
   

   Evidence for	Evidence against

   
   
   Other useful questions for eliciting information are: 'what is actually true about this thought/situation?, what is not true about this situation?, are there facts that you are forgetting or not acknowledging?.
   
   
7. Then you need to work with the patient to come up with more realistic or rational interpretations of their thoughts. This can be done by asking questions such as, 'what's a more reasonable and helpful way of looking at this situation?, what could you tell yourself next time you have this thought?, what would a different person say about the thought?, what advice would you give someone else with this thought?'. These should also be written down for the patient. Most clinicians find that patients learn from carrying out and evaluating tasks as homework
   
   
8. As you might expect, this is a time-consuming process. The patient will not necessarily believe their rational first immediately. Ask them to rate how much they believe the thought before and after you begin examining other rational alternatives. This should give you an indication of shifts in the patient's thinking and you should continue to work through this process until shifts in thinking, small or large, occur.

References and recommended reading:

1. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International Universities Press.
2. Beck, A. T., Rush, A. J., Shaw, B. F. & Emery, G. (1979). Cognitive Therapy of Depression. New York: Guilford Press.
3. Clark, D.M., Salkovskis, P. M., Hackman, A., Middleton, H., Anastasiades, P., & Gelder, M. (1994). A comparison of cognitive therapy, applied relaxation and imipramine in the treatment of panic disorder. British Journal of Psychiatry, 164:759-69.
4. Ellis, A., & Harper, R. A. (1975). A new guide to rational living. California: Wilshire Book Co.
5. Hollon, S. D., Shelton, R. C., & Loosen, P. T. (1991). Cognitive therapy and pharmacotherapy for depression. Journal of Consulting and Clinical Psychology, 59, 88-99.
6. Power, K. G., Simpson, R. J., Swanson, V., Wallace, L.A., Feistner, A. T. C., & Sharp, D. (1990). A controlled comparison of cognitive-behaviour therpay, diazepam, and placebo, alone and in combination, for the treatment of generalized anxiety. Journal of Anxiety Disorders, 4, 267-292.
7. Teasdale, J. D.; Scott, J.; Moore, R. G.; Hayhurst, H.; Pope, M.; Paykel, E. S. (2001) How does cognitive therapy prevent relapse in residual depression? Evidence from a controlled trial. . Journal of Consulting & Clinical Psychology, 69(3), 347-357.
   
   
   

Behaviour modification

Behavioural Assessment? (initial assessment, monitoring progress, modifying treatment)

What are the behaviour therapy techniques?

These techniques are used to decrease problem or dysfunctional behaviour (usually excesses) or to increase or learn desirable or functional behaviour. It is particularly effective for the treatment of externalizing disorders and for developing prosocial and basic living skills in children or in adults with an intellectual handicap.

Behaviour modification starts with a thorough behavioural analysis, which involves specifying and measuring the behaviours to be altered, and identifying the antecedents and consequences controlling these behaviours. This analysis is followed by a systematic program which may include altering the stimuli triggering the unwanted behaviour, shaping up new adaptive (competing) behaviour, and contingency management (using reinforcers for increasing desirable behaviour and costs to decrease the unwanted/dysfunctional behaviour).

After changing particular behaviours, techniques for generalization and maintenance of gains are discussed, along with relapse prevention.

Does it work?

Behavioural interventions are an important component of treatment for a variety of disorders. The specific evidence is discussed in relation to the techniques outlined below.

How do you do it?

Some of the key behavioural interventions and how you do them are outlined below.

What is it?
Exposure techniques are used for all anxiety disorders, particularly the phobias. Essentially, exposure involves confronting the feared situation/event/activity so that the fear decreases, or ideally, extinguishes.

Graded exposure is the most commonly used exposure technique. It involves identifying a patient's fears, and constructing a hierarchy of the least to most feared situations. A graded approach is necessary because of the fear it provokes and few people would be willing to confront this immediately and directly when commencing treatment. Therefore, the individual enters the anxiety provoking situations in graded steps so that anxiety is evoked, but not overwhelmingly so. The individual is then instructed to stay in the situation until their anxiety decreases. By remaining in the situation until the fear subsides, the person learns that it is groundless.

Systematic desensitization is similar in that it involves exposure to a hierarchy of feared objects or situations (often in imagination) while using slow breathing, and/or other relaxation techniques, and cognitive coping self-statements to cope with the anxiety experienced. On exposure, the person is assisted to implement the learned relaxation techniques and use the coping self-statements until the fear subsides. Desensitisation is most often used when it is impossible to confront the fear (e.g., fear of flying) but few GPs will have the time or experience and should refer patients that need this to a Clinical Psychologist.

Does it work?

There are many studies of the use of graded exposure in simple and specific phobias and in agoraphobia with follow up studies showing that the benefit is long lasting (e.g., Munby & Johnston, 1980). Exposure is now used as a component of treatment in social phobia (with cognitive therapy) (Taylor, 1996), in obsessive compulsive disorder (with response prevention) (Abramowitz, 1997), in generalised anxiety disorder (with problem solving and relaxation) (Ladouceur, et. al, 2000) and in posttraumatic stress disorder with exposure both to the memories and to situations evoking the memories (Foa et al., 1991).

How do you do it?
Graded exposure in vivo.

1. It is important to provide a good rationale to the patient when you introduce graded exposure into treatment. The patient will usually find the idea of confronting feared situations quite daunting. Typically, these are situations the patient would have spent a great deal of time prior to treatment trying to avoid and so this will be an unpleasant task. Therefore, a good rationale is crucial before beginning any exposure tasks and if explained properly, the likelihood of the patient actually carrying out the exposure tasks and complying with treatment is increased.
   
   For example,
   'one way of overcoming fear provoking situations that you have avoided in the past is to confront these situations in a gradual manner. I know you get very anxious when X happens (e.g., you see a spider, you give a speech), so I'm not going to ask you to confront your most feared situation straight away. Instead, over the next few weeks, I will be asking you to do a number of tasks that will start off quite easy and get harder, until you are able to do X (most feared situation). While you may still find X difficult, every time you enter an anxiety-provoking situation, your fear should decrease (refer to specific everyday examples such as learning to drive). The more times you so this, the easier it will get, and eventually you will learn that nothing bad will happen to you. Eventually, you should be able to confront your feared situation without overwhelming anxiety'.
   
   
2. The next step is to develop an exposure hierarchy in collaboration with your patient. Ask the patient to write down all the situations/events/activities he or she avoids. Direct the patient to think of situations that range from :
   - extreme anxiety 95-100/100 (where a large number indicates extreme distress in the situation) through to
   - mild 10/100 (where a lower number indicates mild distress in the situation).
   
   Feared situations are seldom simple, for example a person with agoraphobia might fear train travel because they are getting further from home (and help) but also fear crowded trains because escape would not be possible. While only the patient knows the detail of what they fear, the clinician must ensure that the exposure situations address the complexity of the fears.
   
   
3. Next decide upon approximately 10 situations (if the hierarchy is too small then opportunities for improvement is limited) which will be able to be implemented as part of the patient's exposure plan. When deciding on situations that are appropriate, try to choose scenes that are specific (e.g., 'catch bus from A to B at 9:00am Tuesday morning', rather than 'catch the bus') and detailed (e.g., 'have a conversation' is too vague).
   
   
4. Then help the patient organise the situations from least to most feared. This is not always an easy process. However, there are not set rules for guiding this process, just try to arrange the hierarchy in a logical, ascending order. It may be helpful to write the scenes on separate cards and spend some time arranging these.
   
   
5. Ensure that a range of situations have been included in the hierarchy and that there are no sudden jumps in the levels of distress. If there are, have the person add intermediate situations or modify one of their items (if necessary, intermediate steps can be added in once the patient begins undertaking exposure tasks).
   
   
6. The next step is encouraging the patient to begin exposure. Ask them to enter one of the easiest situations on their own and remain until anxiety is halved, then instruct the patient to repeat this until there is little associated anticipatory anxiety about entering the situation. While there is no exact timeframe for how long the patient should remain in the situation, ideally, the patient should be encouraged to stay in the situation for as long as he or she can tolerate (within reason). This should allow ample opportunity to learn that nothing bad will happen and that habituation to anxiety will occur. However, there are often practical constraints that need to be considered. Such constraints will often guide how long the exposure exercise will last. When a particular exposure exercise is brief (e.g., 'initiating a conversation with a stranger'), it should be repeated a number of times.
   
   
7. The patient should then move on to the next situation and repeat until less anxiety occurs.
   
   
8. The patient should do exposure at least three to four tasks per week and you should review progress weekly to ensure he or she is confronting their fears. Any success must be reinforced, even good effort at a task that was not successful is a reason for praise. Once mastery of a situation occurs patients will become pleased and proud and clinicians should reinforce this.
   
   
9. Motivation is often a problem, given the unpleasant nature of what you are asking the patient to do. At times, you will need to remind the patient of the rationale behind exposure and encourage him or her to continue to confront the feared situations until mastery is achieved.

Goal: To travel alone by train to the city and back

Tips:

• ensure that the patient does exposure repeatedly - even if they feel they have conquered their fears
• within reason, allow the patient to determine the rate at which they progress through their hierarchy
• sometimes several smaller hierarchies might be more workable than one large hierarchy, if there are distinct situations that require attention (e.g., attending social gatherings)
• you can also explain exposure to the patient as a 'behavioural experiment' that can be used to test out their fears.For example, if a patient says 'everyone will laugh at me', then you can set an exposure task that will allow them to test out this belief
• if a patient is extremely anxious or resistant prior to an exposure task then you can:
  

- modify their hierarchy
- add more intermediate steps into the hierarchy
- encourage the patient to do the task with a friend or partner

• keep in mind that a patient's progression through their hierarchy will not always run smoothly. At different times and for various reasons (e.g., lack of motivation, a change in personal circumstances), they will experience setbacks and it will be necessary to remind him or her about the rationale for exposure and encourage persistence with the hierarchy.
• it may helpful if you ask the patient to keep a diary, so he or she can record their anxiety levels and any problems that were encountered.

Special Issues in Obsessive Compulsive Disorder (to be added)

Special issues in Bulimia (to be added)

Special Issues in the treatment of sexual disorders (to be added)

References and recommended reading:

1. Abramowitz, J. S. (1997). Effectiveness of psychological and pharmalogical treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 65, 44-52.
2. Andrews, G., Crino, R., Hunt, C., Lampe, L. & Page, A. (1994). The Treatment of Anxiety Disorders. Melbourne: Cambride University Press.
3. Andrews, G. & Hunt, C. (1998). Treatments that work in anxiety disorders. Medical Journal of Australia, 168, 628-634. 4. Foa, E. B.; Rothbaum, B. O.; Riggs, D. S.; Murdock, T. B. (1991).
4. Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting & Clinical Psychology, 59, 715-723.
5. Ladouceur, R., Dugas, M. J., Freeston, M. H., Leger, E., Gagnon, E., & Thibodeau, N. (2000). Efficacy of a cognitive-behavioural treatment for generalised anxiety disorder: Evaluation in a controlled clinical trial. Journal of Consulting and Clinical Psychology, 68, 957-964.
6. Munby, J. & Johnston, D.W. (1980). Agoraphobia: long-term follow-up of behavioural treatment. British Journal of Psychiatry, 135, 418-27.
7. Taylor, S. (1996). Meta-analysis of cognitive behavioural treatments for social phobia. Journal of Behaviour Therapy and Experimental Psychiatry, 27, 1-9.
8. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.

What is it?

This technique is mainly used to assist patients with depression. Activity scheduling is a useful strategy to teach patients who have both lost interest in doing things they enjoy and who find it difficult to do basic daily tasks. It is particularly important to increase pleasurable activities when people feel depressed, as they feel less inclined to engage in activities that are a source of pleasure and satisfaction. Similarly, when people are not involving themselves in activities they consider pleasant, this can make them feel depressed. This creates a vicious cycle and in order to break this pattern of inactivity patients need to learn how to keep active when they feel down. Activity scheduling is a behavioural technique designed to mobilise the patient and to increase the range and frequency of pleasant activities engaged in. The overall aim is to teach patients how to increase their activities in a structured and organised manner, thereby increasing mood. Activity is the key, and mastery of tasks, pleasant activities, or exercise should be reinforced.

Does it work?

Activity scheduling is an effective behavioural treatment for depression (see Lewinsohn & Gotlib, 1995).

How do you do it?

1. If a patient is not engaging in their usual activities, both routine (e.g., household duties) and pleasant (e.g., going to the movies), then it will be important to explain to the patient why they need to continue doing these activities. For example, 'you've told me that you no longer have the energy or motivation to do what you need to do and you have stopped doing things you enjoy. People often don't feel motivated when they are feeling down and sometimes stop doing the things they need to do and also stop doing the things they enjoy. It is important that you don't stop doing these things as the less you do the worse you will feel, and the worse you feel the less you will do.'
   
   
2. Ask the patient to tell you what things they are doing now and write these down. Then, ask the patient to rate their sense of achievement and how much pleasure they derive from performing these activities (on a scale from 0 to 6, where 0 = no pleasure or sense of achievement, 6 = high pleasure and sense of achievement).
   
   
3. The next step is to ask the patient to list all the things they should be doing but are not doing at the moment (e.g., grocery shopping). Then ask the patient to list at least ten things they would like to be doing and used to enjoy (e.g., meeting a friend for coffee, for further suggestions refer to 'Pleasant things to do', Management of Mental Disorders (2000), page 225).
   
   
4. If possible, activities should be arranged hierarchically - easiest to hardest - and each week, beginning with the easiest items, one to two activities will be chosen. Where necessary, complex activities (e.g., starting a course) should be broken down into smaller steps.
   
   
5. Discuss with the patient that it is important to try and achieve a balance between pleasurable activities and activities that are not pleasant but must be done.
   
   
6. With the patient, show them how to plan their activities in a structured manner. You can do this by going through their day hour by hour for the coming week or use the handout in Management of Mental Disorders (2000), on page 223-224.
   
   
7. Make sure you start off slowly and only schedule 1-2 pleasant activities in the first week. Do not try and fill every hour of the day. Even if the patient only does one pleasant activity during the week, this is better than doing none at all and will help give the patient a sense of mastery. You can increase the number and range of activities in the coming weeks. Don't forget to remind the patient to rate their sense of pleasure (P) and achievement (A) after completing the activity.
   
   
8. Ask the patient to record any other activities that occur and were not pre-planned. Ask them to rate their (P) and (A) for these too.
   
   
9. Remind the patient to bring their activity schedule to their next appointment. Review what went well and what did not go so well. Provide encouragement and try to build on what was achieved the previous week
   
   
10. Encourage the patient to continue planning their activities until they resume their normal routine.

Sample Activity Schedule

Date: 1st March

Rating scale for sense of pleasure (P) and sense of achievement (A)

Tips:

• encourage patient to set aside time to plan their day (e.g., the night before)
• suggest that the patient start the day with activity that will provide both pleasure and achievement
• explain how exercise has been shown to help alleviate depressed mood (e.g., Lane & Lovejoy, 2001) and try to encourage the patient to make time in their day for this activity
• encourage the patient to be flexible - reschedule activities as needed and add other activities as they occur.
• aim for quality not quantity (e.g., 15 minutes of walking is better than aiming for a 1 hour run).

References and recommended reading:

1. Lewinsohn, P. M. & Gotlib, I. H. (1995). Behavioral theory and treatment of depression. In E. E. Becker & W. R. Leber (Eds.), Handbook of depression (pp. 352-375). New York: Guilford Press.
2. Lewinsohn, P. M., Munoz, R. F., Youngren, M., & Zeiss, A. M. (1978). Control Your Depression. New York: Prentice Hall Press.
   
3. Lane, A. M. & Lovejoy, D. J. (2001). The effects of exercise on mood changes: the moderating effect of depressed mood. Journal of Sports Medicine & Physical Fitness. 41(4):539-45.
   
4. Tanner, S. & Ball, J. (2000). Beating the Blues. A Self-Help Approach to Overcoming Depression. Southwood Press.
   
5. Treatment Protocol Project (2000). Management of Mental Disorders (Third Edition). Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse.