I remember meeting Sarah*, a young mum, during a six-week postnatal checkup. She was struggling with postnatal depression and felt overwhelmed.
Medication wasn’t her preference, and the waiting list for therapy was long. These were the options I usually discussed. “Will I ever feel like myself again?” she asked. How could I respond?
As community-based health professionals – whether nurses, midwives or GPs – we often meet people like Sarah, individuals whose mental wellbeing is impacting their daily lives.
It is not uncommon for patients to not want to take medication – and indeed, in mild-to-moderate cases of low mood, medication is less likely to be effective – and there can be barriers or reluctance for psychology or counselling support. What can we add in these cases?
Rediscovering life
Behavioural activation is a part of cognitive behavioural therapy (CBT). It is one of the quickest and most effective options for depression, with changes seen in just a few weeks. It is perfectly suited to be used in a community setting, where we need simple and effective options to discuss with our patients to improve their mood.
Practical tools
But how do I do “behavioural activation,” you may ask. Here are two types of questions that can help you put this theory into practice.
Coping questions
These questions help identify current coping mechanisms:
- “How are you coping?” (It’s okay to ask this more than once!)
- “In the last week, what has helped you cope?”
- “What gives you strength day to day, to be able to cope and not give up?”
- “What things will help you cope this week if there are tough moments?”
Common answers include:
Routine: “I keep going with the things I have to do each day, like making the lunchboxes and getting the kids to school.”
Activity: “Getting outside to clear my head.”
Connection: “I talk to my friends.”
We can use these answers to come up with an activity-focused plan with our patient. We may talk about building on a strategy by discussing adding to the existing:
Routine: “It sounds like a routine really helps you when things are tough and you feel like you are just going through the motions. I wonder if we could add to your routine, for example, walking to meet the kids from school so you get some time outside, or maybe you have other ideas of something small we could add to your routine to support your mental health?”
Activity: “It sounds like being outside gives you clarity when you are feeling low or stressed. Could it be worth us coming up with a plan so you regularly get little bits of time outside? What could be possible with how life is at the moment?”
Connection: “How often would you get a chance to talk to your friends? Is there a way to make this a regular thing? Have you talked to any of them about your health? Do you think that would be helpful?”
Once we have this personalised information, we could put it into a specific plan, which could be to try gardening for about 20 minutes after work twice in the next week. It is important that the person feels confident that they can succeed, even if we need to start smaller and suggest, for example, five minutes of gardening as a start.
Treasure hunt questions
Another way to ask a question to help with behavioural activation is a “treasure hunt” question. These questions uncover activities the person used to enjoy or find helpful:
- “When you felt better a few months ago, what did a typical day look like?”
- “What activities have you enjoyed in the past?”
- “What did you do for fun before you felt like this?”
If someone is restarting an activity, it can be more of a challenge than increasing or working with something they are already doing. We want to start small but still be activity-focused.
So ideally, someone may say they will plan to start walking. Rather than them just thinking about walking and other exercise options, we might like to make a more specific, action-focused plan. It could be to look online at the local gym classes and at a potential walking route.
These plans can be used instead of, or alongside, other options like medication and therapy. It is important to have a back-up plan in place for if things worsen; a good option can be the free phone/text 1737.
Always make a plan to follow up to see if things have improved, or adjust and reconsider the plan if there has not been any improvement. Sometimes you will find small changes can make a big impact.
Making a community-based plan
When working with Sarah, we discovered she used to love painting. She still has all the things she needs at home to restart this. Together, we created a plan: she would try getting out her materials and doing this again one day in the evening once her partner is home.
She suggested she spend one nap time every day on this, but we agreed that an initial goal could be to spend some of a nap time two to three times in the next week painting. I would speak to her again in a week’s time with a phone consult follow up.
Summary
By using coping and treasure hunt questions, health-care professionals, including nurses and midwives, can help people reconnect with activities that bring them joy and meaning.
Behavioural activation empowers individuals to take small, manageable steps toward improved mental wellbeing. The beauty of this approach is its simplicity and accessibility. Small changes really can make a big difference.
* Sarah is a fictional patient based on encounters with real patients over the author’s career.
Sophie Ball is a GP with a strong interest in straightforward conversations about mental health, and co-author of a recently published book What do I say next? Everyday mental health conversations in primary care. For further information about the book, go to www.drsophiejadwigaball.com This article is adapted from one originally published in NZ Doctor.