What does 'being more active' look like if you can’t leave the house?
Behavioural activation is usually used to help people who have stopped doing rewarding activities due to low mood. What does it look like when people’s activities have been taken away from them?
Imagine barely leaving your house for ten months. You can’t even distract yourself with Netflix or connect to friends on Zoom, as you can’t get online. That’s the case for many of the service users I work with as an Assistant Psychologist in an Older People’s Psychology Service based in the community. They are so worried about the Coronavirus that they have been shielding since February, before the Government’s official edict, and haven’t stopped since. The majority of our service users also don’t have access to the Internet, due to lack of equipment, confidence or skills.
Prior to the pandemic, many of these people were leading social and relatively independent lives. Their weeks were filled with activities such as attending day centres, church services or exercises classes, or simply running errands and seeing friends. Now they are understandably feeling low, anxious and less able to cope with daily life like they did before. The impact is even greater for people who had pre-existing mental health difficulties. With the loss of distractions, distressing thoughts and emotions become more dominant.
Recent research by Age UK suggests that our clients are not unique in this. It found that 45% of people aged over 70 feel either uncomfortable or very uncomfortable about leaving the house due to the coronavirus pandemic. Unsurprisingly, this is having an impact on their mental health. According to Age UK, the number of over 70s experiencing depression has doubled since the start of the pandemic and one in three older people report that their anxiety has got worse.
Staying at home doesn’t just have a psychological impact. A lack of physical movement and mental stimulation can also affect older people’s physical and cognitive functioning. For example, one in four of older people in the Age UK survey reported feeling less steady on their feet, and one in five said they are finding it harder to remember things. For many of them, there is a fear that they will never get back to the same quality of life they had prior to the pandemic.
One aspect of my role is doing behavioural activation with older people who are experiencing low mood. The aim is to help people re-engage with rewarding activities that matter to them. When we’re feeling low, we can fall into a self-reinforcing cycle of avoiding activities that might help us feel better, which makes us feel even worse and less like doing things. Using techniques such as activity scheduling can help to break this cycle (Veale, 2008).
Evidence suggests that behavioural activation is effective in alleviating symptoms of depression in older people in the community (Orgeta, Brede & Livingstone, 2017). However, most of the people I’m working with now are feeling low because their usual activities have been taken away, not vice versa. What is the role of doing behavioural activation in this context?
I spoke with a colleague in our local recovery unit, who works with people who tend to have more acute and complex mental health difficulties. The observations below are based on our reflections of doing remote work, so they may not be generalisable. However, I hope they will provide a starting point for discussion and future research.
Assessing the conditions for phone work
Part of any assessment entails working out what might be appropriate in terms of a psychological intervention. In the current circumstances, this includes ascertaining whether it is possible to work together over the phone or video call (typically the former due to the digital access issues I've mentioned). There may be several barriers to this. For example, hearing loss is common for older people and sometimes this makes communication on the phone too difficult, as the person lacks the additional information provided by lip reading and facial expressions.
Memory issues can also make phone work difficult. Can the person remember you between calls and orientate to the context, perhaps with some prompts? It’s also important to discuss how the client will remember that you are calling. Could they write in a diary, would a text reminder help or would they like me to let a family member know about the appointment times so they can remind them?
As with all activation work, it’s important to get a sense of the person’s values. What matters to them and thus what would be rewarding? Typical behavioural activation worksheets focus on various life roles/areas, some of which may be less significant for older people, such as work and family roles. If somebody is quite unwell or has cognitive difficulties, worksheets can also be overwhelming. I tend to take a slower and less formal approach, using the same broad topics to inform my questions, but with a focus on adaptation. For example, if that person had a job in the past, what did they like about it? If they enjoyed the feeling of mastery of a skill and being useful, are there ways they could fulfil this value at home, such as doing DIY? What did they enjoy doing prior to lockdown? If they liked the ‘hustle and bustle’ of visiting the shops, could they sit at their window and 'people watch'?
Setting realistic goals
Many of the older people we work with need support to be active because of additional needs, such as physical health difficulties that affect their energy levels, mobility issues, or cognitive impairments that make it harder to motivate themselves or organise activities. They are also more likely to be socially isolated. This is why the loss of external structures, such as day centres, is having such a big impact.
Given these barriers, it’s important to set small goals and to go at a slow pace. It’s useful to get a granular understanding of a client’s routine. When do they tend to wake up? Which parts of the day are most difficult? What parts to they enjoy or find easier to cope with? Identifying these moments is a useful starting point to build on.
As activities tend to be limited to in and around the home, it’s also important to get a sense of the environment, for example does the person have a garden? Is their home cluttered and does this negatively impact their mood or ability to engage in activities? The more you understand about somebody’s circumstances, the easier it is to make small, achievable suggestions. For example, could watering the house plants or doing light housework bring a sense of satisfaction? Activities that can be done in increments throughout the day, such as jigsaw puzzles or mindful colouring in (which may be posted to the client), have also proved successful.
Providing a thinking space
For some of the clients we work with, it can be difficult to generate or plan an activity, so acting as a thinking partner is helpful. For example, a client may not want to call their friends as depression or memory difficulties have slowed up their thinking and they are afraid of having nothing to say. In that case, it may help to identify two or three people they would like to call and think together about a suitable topic for each call. Or perhaps they would like to do some creative writing, but are unsure of what to write about; in which case coming up with a topic together can help. In line with general behaviour activation work, the more specific you are about the task, the more likely the client is to carry it out.
When working with older people, it is often helpful to think systemically. Who else is, or could be, involved in helping the client? If somebody has a relative who visits frequently, I may ask their consent to phone them and share the goal for the week so they can encourage them and, if needed, acquire the necessary materials. They may have a friend whom they speak to regularly and we agree they will talk to the friend about the planned activity, as this increases the likelihood they will complete it. Or we may focus on helping them make the best use of other kinds of support such as paid carers. I also frequently make referrals to telephone friendship services that can provide ongoing social contact.
Making space for loss
The people we are working with have experienced considerable losses, including loss of social contact, loss of daily routine, loss of independence, loss of functioning or loss of loved ones due to the coronavirus or other illnesses, as older people are more likely to experience bereavement. For some clients, anxieties about coronavirus and news stories about daily death tolls have also triggered painful thoughts and feelings about previous bereavements.
It is important to acknowledge and make space for feelings about loss to be expressed during sessions and to frame the intervention in the context of this. The goal is to help the client think about how they cope and whether there are opportunities to engage in activities that may bring a sense of enjoyment or at least respite, while being realistic about the fact that yes, this is a difficult time, and many things are out of our control.
Exploring positive risk taking
It can be challenging to deliver a psychological intervention when the scope for change or improvement is limited due to overwhelming external contexts that are beyond the control of either me or the client. This is a feature of much clinical work to some extent, but it looms particularly large when working with vulnerable people during Covid. I’m sometimes left feeling quite frustrated and even angry about the situation, wondering whether it is really worth sacrificing older people’s emotional well being (and functioning), or if there could be a more balanced approach.
Of course that is not my decision to make. Some clients bring this as a dilemma and use part of our sessions to explore taking positive risks, such as going for a walk with a friend or bringing back practical support to help them cope, such as a cleaner or carer. It’s important to name the dilemma and help the person consider the risks rather than advise them either way.
I sometimes share the client’s feelings of helplessness and sadness, and it can be difficult to ‘hold the hope’ for them. However, with patience and persistence, it often is possible to help somebody rediscover a degree of enjoyment, connection and agency. It is important to recognise and celebrate progress, both for the client and for me, while being realistic about the scope of our work. Like my clients, I have had to learn to manage my own frustration, accept what we cannot change and take satisfaction helping somebody take small steps to make their situation easier to cope with.
- Sarah O'Reilly is an Assistant Psychologist in a community mental health service for older people.
Age UK (2020). The impact of COVID-19 to date on older people’s mental and physical health.
Orgeta, V., Brede, J., & Livingston, G. (2017). Behavioural activation for depression in older people: Systematic review and meta-analysis. British Journal of Psychiatry, 211(5), 274-279. doi:10.1192/bjp.bp.117.205021
Veale, D. (2008). Behavioural activation for depression. Advances in Psychiatric Treatment, 14(1), 29-36. doi:10.1192/apt.bp.107.004051
Yip PS, Cheung YT, Chau PH, Law YW (2010). The impact of epidemic outbreak: the case of severe acute respiratory syndrome (SARS) and suicide among older adults in Hong Kong. Crisis 2010; 31: 86–92.
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