Patient Experiences and Opinions of a Behavioral Activation Group Intervention for Depression

Abstract

Purpose
Major depressive disorder is the leading cause of disability worldwide. This study is part of a mixed methods pilot trial, exploring the effectiveness, acceptability, and feasibility of providing behavioral activation (BA) treatment in a group format.

Methods
Using an applied, descriptive approach, qualitative data were collected from individual interviews (18) and focus groups (5) at multiple data points throughout the trial and feedback given to group facilitators, who adapted the program accordingly.

Results
Group BA is an effective and acceptable treatment format when a client-centered, flexible approach is utilized. This contrasted with findings from the comparison intervention, a peer support group, from which participants reported no benefit.

Conclusions
Group BA is beneficial in a fiscally responsible evidenced-based health-care culture. Comparator groups need to be carefully selected. Engaging patient and clinician perspectives when designing and implementing new clinical interventions is vital in informing future research and social work practice.

Full text

Research Article
Patient Experiences and Opinions of a
Behavioral Activation Group Intervention
for Depression
Laura O’Neill
1,2
, Zainab Samaan
1,2,3,4
, Kathleen McCabe
1,2
,
Terri Ann Tabak
1,2
, Brenda Key
1,2
, Kathryn Litke
2
, Jeff Whattam
2
,
Laura Garrick
2
, Sandra Chalmers, Feng Xie
3
,
Lehana Thabane
3,5,6,7,8
, Yogita Patel
2
, Hamnah Shahid
1
,
Laura Zielinski
1
, and Meredith Vanstone
9
Abstract
Purpose: Major depressive disorder is the leading cause of disability worldwide. This study is part of a mixed methods pilot trial,
exploring the effectiveness, acceptability, and feasibility of providing behavioral activation (BA) treatment in a group format.
Methods: Using an applied, descriptive approach, qualitative data were collected from individual interviews (18) and focus groups
(5) at multiple data points throughout the trial and feedback given to group facilitators, who adapted the program accordingly.
Results: Group BA is an effective and acceptable treatment format when a client-centered, flexible approach is utilized. This
contrasted with findings from the comparison intervention, a peer support group, from which participants reported no benefit.
Conclusions: Group BA is beneficial in a fiscally responsible evidenced-based health-care culture. Comparator groups need to
be carefully selected. Engaging patient and clinician perspectives when designing and implementing new clinical interventions is
vital in informing future research and social work practice.
Keywords
behavioral activation, depression, client centered or patient centered, qualitative
Major depressive disorder (MDD) is the leading cause of
disability worldwide, with an estimated 350 million people
sufferingfromit(WorldHealthOrganization[WHO],2004,
2012). MDD is characterized by depressed mood, loss of
interest or pleasure, and other symptoms such as fatigue, dif-
ficulties with concentration and decision-making, and feel-
ings of worthlessness and guilt. Some individuals may also
experience suicidal ideation or attempt suicide (American
Psychiatric Association, 2013). These symptoms often lead
to social isolation and a reduction in activities (American
Psychiatric Association, 2013). The magnitude of this global
health-care problem illustrates an immediate need for acces-
sible and cost-effective treatments to meet the needs of those
affected with depression. The importance of developing and
researching effective treatments for depression cannot be
overemphasized.
Behavioral activation (BA) is a component of cognitive
behavioral therapy (CBT) that was originally proposed as a
stand-alone treatment of depression by Jacobson and
colleagues in 1996. BA targets withdrawal and avoidance
behaviors, commonly seen in patients with MDD, which may
1
Department of Psychiatry and Behavioral Neurosciences, McMaster Univer-
sity, Hamilton, Ontario, Canada
2
Mood Disorders Program, St. Joseph’s Healthcare Hamilton, Hamilton,
Ontario, Canada
3
Department of Health Research Methods, Evidence, and Impact, McMaster
University, Hamilton, Ontario, Canada
4
Population Genomics Program, Chanchlani Research Centre, McMaster
University, Hamilton, Ontario, Canada
5
Centre for Evaluation of Medicine, McMaster University, Hamilton, Ontario,
Canada
6
System-Linked Research Unit, McMaster University, Hamilton, Ontario,
Canada
7
Department of Anaesthesia, McMaster University, Hamilton, Ontario,
Canada
8
Department of Paediatrics, McMaster University, Hamilton, Ontario, Canada
9
Department of Family Medicine, McMaster University, Hamilton, Ontario,
Canada
Corresponding Author:
Meredith Vanstone, David Braley Health Sciences Centre, McMaster University,
Room 5003E, 100 Main St. W, Hamilton, Ontario, Canada L8P 1H6.
Email: meredith.vanstone@mcmaster.ca
Research on Social Work Practice
1-9
ªThe Author(s) 2018
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DOI: 10.1177/1049731517749942
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exacerbate depressive symptoms (Jacobson, Martell, & Dimid-
jian, 2001). To assist patients with depression and address these
patterns of behavior, BA provides patients with skills and sup-
port systems to engage in a variety of mastery and pleasurable
activities that act as antidepressant behaviors (Jacobson et al.,
2001). BA adopts a goal-oriented approach and utilizes tools
such as activity tracking and scheduling, graded task assign-
ments, and problem-solving strategies to help clients achieve
their goals, thus increasing activation and the likelihood of
experiencing positive reinforcement (Soucy & Provencher,
2013). In essence, BA modifies an individual’s environment
to intervene with depressive thoughts and behaviors, rather
than targeting their thoughts directly (Jacobson et al., 2001).
A Cochrane review investigating the effectiveness of BA
found low to moderate evidence that BA is equally effective
as other psychological treatments (e.g., CBT, psychodynamic
therapy, and interpersonal therapy). The review suggested that
recruiting larger samples with improved reporting of design
would improve the quality of this evidence (Shinohara et al.,
2013). When compared to antidepressant medications, BA out-
performed medications in terms of percentage of participants
both adhering to treatment and reaching remission, while also
producing equal outcomes on both self-report and clinical rat-
ings (Dimidjian et al., 2006). Furthermore, BA has many poten-
tial advantages over other forms of treatment. Specifically,
individuals with poor verbal skills or significant cognitive def-
icits can participate in BA, BA is structured and easy to deliver,
and it is less costly than CBT and pharmacological interven-
tions (Sturmey, 2009). Although normally delivered by a thera-
pist one-on-one with the client, recent studies have investigated
the use of a group format for BA which can further address the
current gap between available treatment options and demand
for these services by delivering it to several patients at once
(Porter, Spates, & Smitham, 2004). It has been hypothesized
that perhaps the social interaction in a group may serve as a
positive reinforcer in its own right (Porter et al., 2004). Current
literature reveals promising results, showing that group BA
produces statistically significant therapeutic outcomes for indi-
viduals with MDD (Houghton, Curran, & Saxon, 2008; Porter
et al., 2004; Richardson et al., 2005; Wesson, Whybrow,
Gould, & Greenberg, 2014). BA’s ease of access, minimal time
investment, and cost-effectiveness make this therapy an
appealing alternative to traditional forms of treatment. Before
BA can be recommended as a mainstay therapy in a resource-
limited health-care setting, more research is needed to determine
whether the results of preliminary research can be replicated
using randomized controlled trials (RCTs) and other evidenced-
based methodologies. The importance of including client
experiences to shape both the intervention protocol and the clini-
cally relevant outcomes (Crow et al., 2002; Guyatt, Montori,
Devereauz, Schinemann, & Bhandari, 2004; Lawton, Rankin,
& Elliot, 2013) is a key factor in research and one that we view
as essential in health-care systems claiming to be client centered.
Additionally, it has been suggested that qualitative research has
a central role to play in feasibility studies for RCTs, and this
developing area requires more attention (O’Cathain et al.,
2015). Thus, the current study aims to engage and encourage
patients in contributing to our main RCT to test the effectiveness
of a BA group for depression. Given social workers’ prominent
role in counseling and psychotherapy, the professionhas much to
gain from knowledge of the current research on innovative and
effective treatments for depression.
Objectives
This article describes the development and implementation of
the qualitative component of a mixed methods RCT pilot study
(Samaan et al., 2015, 2016). BA is usually provided as an
individual therapy, and we set out to explore the effectiveness,
acceptability, and feasibility of enhanced BA in a group format
with outpatients diagnosed with MDD. In the process of doing
this, we also demonstrate a method of rigorously soliciting and
incorporating client feedback to enhance the intervention under
studyinaresearchtrialwiththe aim of ensuring a client-
centered intervention.
Method
In this section, we provide a brief description of the pilot trial
followed by a more detailed explanation of our qualitative
methods. We have previously described the development of
this project alongside the aims and measures for both the quan-
titative and qualitative portions of the trial in detailed study
protocols (Samaan et al., 2015, 2016).
The aim of the mixed methods pilot trial was to establish the
feasibility and acceptability of a group BA intervention for
patients with MDD. Recruitment was through a Mood Disor-
ders Outpatient Program. Potential participants were
approached by their clinicians and, if interested, they partici-
pated in an initial screening for eligibility. Inclusion criteria
required a primary diagnosis of MDD. As shown in Figure 1,
the participants were randomized to either the enhanced BA
intervention group (n¼10) or the patient-led peer support con-
trol group (n¼10). In each group, there were six women and
four men. Table 1 shows the age distribution of all participants.
In the first phase, both groups met for 2 hr twice weekly for
10 weeks. In the second phase, the intervention group met indi-
vidually with a group facilitator once a week for 6 weeks and as
a group once a week for 2 weeks. The individual meetings were
an opportunity to review and consolidate the core information of
BA. Facilitators (a social worker, an occupational therapist, and
a recreational therapist) trained in BA provided the intervention.
In the second phase, the comparator group met together once
weekly for 8 weeks. The facilitators for this group were mental
health nurses (registered nurses without BA training) who had
the goal of encouraging and supporting a peer-led group. This
type of comparator group was selected by the team as we wanted
to explore, and potentially rule out, if merely attending a clinic
group twice per week and making contact with supportive peers
was activation enough to improve mood and functioning. Leav-
ing the house and attending a group is in itself a change of
behavior or BA, and we questioned whether this would be an
2Research on Social Work Practice XX(X)

active ingredient as compared to the BA treatment protocol. All
patients continued their preexisting course of treatment for MDD
throughout this pragmatic pilot trial.
The enhanced BA protocol was developed using evidence
and information from a variety of clinician, research, and
patient sources (Samaan et al., 2015, 2016). The enhanced
BA protocol included all the core components of BA and, in
addition, sessions on assertiveness/communication, mindful-
ness, rumination, problem-solving through cooperative games,
healthy eating, sleep, information on volunteering and return-
ing to work, and community outings planned by the partici-
pants. Participants wore activity tracking devices (Fitbit One)
that provided real-time and weekly computerized individua-
lized progress reports (Chum et al., 2017).
This study was conducted at an outpatient specialized mood
disorders clinic in urban Ontario, Canada. Recruitment through
this tertiary clinic resulted in many of the patients falling on the
most severe and chronic range in terms of their depression
symptoms and length of illness. The pilot study was approved
by the Hamilton Integrated Research Ethics Board.
Qualitative Study Design
We used the methodology of qualitative description, as
described by Sandelowski (2000). This methodology is
appropriate for a study that aims to produce findings that are
close to the data and are not interpreted into a grander theory.
Qualitative description studies take a naturalistic approach to
the phenomenon under study. The aim of this applied research
study was to gather client perspectives at multiple points and
integrate suggestions for improvement into the intervention as
the pilot study progressed. This iterative process contributes to
the design of an enhanced BA group intervention, which is
client centered and promotes a positive experience to achieve
high participant retention. Interviews encourage the telling of
personal stories and often generate valuable information for the
researchers, as participants are able to share their lived experi-
ences (Whittaker, 2009) of depression and the impact of the BA
group and the peer support comparator group.
Table 2 shows the multiple data collection points for the
qualitative study. All 20 participants were invited to contribute
and 18 completed the study. Two participants (one from each
group) withdrew from the trial due to surgery (BA group) and a
psychiatric admission (peer group).
Data collection began with 18 semistructured individual
interviews lasting approximately 1 hr. The purpose of these
initial interviews was to gather information about the group
experience (i.e., what was helpful and what needed to be
adjusted or changed). Individual interviews provided a venue
should the participants wish to discuss more personal experi-
ences of depression or aspects of the group that they were
reluctant to discuss in the focus group setting. It became clear
in the first focus groups that participants felt comfortable dis-
cussing personal experiences of depression and the benefits and
critiques of their respective group’s content and process. Thus,
postgroup individual interviews were not conducted.
Data collection proceeded with multiple focus groups held
with the BA, control, and facilitator groups. These groups were
held separately; six to eight participants attended each of the
patient focus groups. Four of the five facilitators attended the
facilitator focus group.
Focus groups enabled participants to build off each other’s
ideas and respond to the feedback shared by other participants.
The questions asked were not particularly personal or sensitive,
and therefore, this method was an appropriate way to collect
data (Kitzinger, 1995; Sim, 1998). The focus group discussions
concentrated on the participants’ experiences and views of their
respective groups in order to obtain feedback that might be
Individuals approached
n = 27
Individuals consenting to
participate
n = 20
Individuals not interested
n = 7
Total participants completing
qualitative study
n = 18
Individuals in BA Group
n = 9
Individuals in Peer Support Group
n = 9
Figure 1. Flow diagram for participants included in study.
Table 1. Age Groups of Participants.
Age in Years BA Intervention Peer Group Control
25–35 1 1
36–45 2 3
46–50 2 3
51–60 4 1
61–70 1 2
Total 10 10
Note. BA ¼behavioral activation.
Table 2. Data Collection Points.
Participant Type
Week 2 Week 4 Week 5 Week 18
Session 4 Session 8 Postsession 28
BA intervention
group
Individual
interviews
Focus
group
Focus
group
Peer support
control group
Individual
interviews
Focus
group
Focus
group
Facilitators Focus
group
Feedback
session
Feedback
session
Note. BA ¼behavioral activation.
O’Neill et al. 3

used to modify the BA protocol for the main trial. Participants
were informed their opinions and suggestions would be imple-
mented immediately where possible and would all be consid-
ered when planning the main study. A semistructured interview
guide was used, and the facilitator permitted discussion to flow
freely and to allow participants to raise issues important to
them while acknowledging the research process and the
socially constructed nature of that which is being studied
(Charmaz, 2000, 2006; O’Grady & Skinner, 2012). The
approximately 1-hr focus groups were facilitated by L.O. and
M.V. One facilitator of the focus groups asked questions and
led the discussion, while the other wrote field notes, observing
group dynamics, body language, and other aspects that are not
recorded on audiotape (Kitzinger, 1995).
Facilitators from both arms of the study participated in a
facilitator focus group during the intervention to explore their
experiences and opinions about the content and process of their
relative groups. The longitudinal design with multiple data
collection points allowed a researcher (L.O.) to meet the facil-
itators in order to provide two feedback sessions about partici-
pant experiences and suggestions. Where possible, the
facilitators used this feedback to adjust the groups as necessary
to foster a client-centered approach in the development and
implementation of the intervention arm of the study and to
modify the study protocol planned for the main trial. Adjust-
ments to the programming were made when it was possible to
do so without disrupting theoretically relevant content for the
trial. This collaboration between patients, clinicians, and
researchers aligns with the aspiration to provide client-
centered care, whereby the development of new services or
treatments is responsive to patients’ values, preferences, and
requirements (Guyatt et al., 2004; Lawton et al., 2013).
Data Analysis
The focus groups and individual interviews were audio-
recorded and transcribed verbatim for analysis (Poland,
1995). A staged analysis was conducted based on grounded
theory coding techniques including line-by-line coding, the-
matic coding, and constant comparative analysis (Boeije,
2002; Corbin & Strauss, 2008; Poland, 1995). The data were
reread and reanalyzed as themes were identified. Following
some initial analysis, the qualitative researchers (L.O. and
M.V.) also met with the principal investigator of the trial
(Z.S.) to discuss and develop a framework of themes for data
coding and further analysis.
Results
BA for depression is usually delivered on an individual basis.
Our analysis established that an enhanced BA group was effec-
tive, acceptable, client centered, and feasible in the treatment of
depression. We also demonstrate the possibility of using a
research-based approach to solicit and integrate client input
over the course of an intervention-based trial. Four key findings
emerged during data analyses, which are of interest to those
who wish to adopt individual BA to a group format and will
guide our main study. First, effectiveness was attributed by
participants to the strong connection between improved mood,
functioning, and social cohesion. Second, the structure, fre-
quency, and content of the BA group were acceptable to parti-
cipants. These three components were found to improve BA or
functioning and nurture group cohesion. Third, a flexible,
client-centered approach was found to best meet the needs of
this complex population who often have multiple diagnosis or
health-care needs. Fourth, feasibility was demonstrated by par-
ticipant feedback on the logistics of the program. Implementing
participant suggestions within the pilot trial and later in our
main trial was also feasible. An unexpected finding that has
implications for our main trial and future research is the selec-
tion of comparator groups. The peer-led support group showed
no benefit but, more importantly, it may be detrimental in this
specific population: individuals with a severe, chronic depres-
sion diagnosis.
Effectiveness—Improved Mood, Functioning, and Social
Cohesion
All participants entered this study with severe and chronic
depression. Participants in the enhanced BA group described
an improvement in their mood, functioning, and increased
social support (family and peer). Participants in the comparator
group did not report the same positive changes. Early inter-
views from both groups confirmed that depression has a strong
impact on functioning, affecting activities such as sleep, moti-
vation, work, relationships, and social isolation:
There are days where I will not leave the house. If I’m lucky, I will
get dressed, likely I won’t shower or get washed, and I will move
from the computer, back to the couch, to the bed, back to the
computer, putter around the kitchen, wash some dishes, and that’s
about it.
During the early interviews, participants expressed personal
goals and hopes that included finding happiness in being
around others, restoring their motivation and energy, feeling
more positive about self, returning to the workforce, doing
more activities with family, returning to hobbies/activities, and
getting out of the house more.
After the groups were completed, participants were asked
what progress they had seen toward their goals. Participants in
the peer support group did not report reaching any of their
hoped for goals with the majority citing no change (two parti-
cipants described very small changes in their behavior or func-
tioning, e.g. citing coming to the group as a change in
behavior). In contrast, the BA group participants reported the
following outcomes, “learning how to prioritize with no more
wasting time on stuff,” setting and achieving goals, going from
avoiding all phone calls and family/friends activities to using
the phone daily to connect with family and friends, and attend-
ing family functions. BA participants had not returned to work
(a couple were taking courses or working on action plans
4Research on Social Work Practice XX(X)

leading to a return to work), but they widely reported increased
activity levels and functioning. One single parent stated the BA
program gave her “a chance to refocus, to get perspective, and
make decisions about the future.”
Participants in the BA group connected these positive
changes to specific strategies learned in the group, to the struc-
ture and frequency of the group, and to the interaction with
other group members. Common sentiments included: “I feel
better, I look forward to coming here, my attitude has changed”
and “When we leave here, we’re all pretty much more up”
(improved mood). Some participants described family mem-
bers and friends remarking on the improvement. For example,
a BA participant who rarely left home and isolated herself from
her husband within their home reported her spouse’s positive
comments on her progress in doing more tasks inside and out-
side the home. She described the BA group as integral in
making changes:
I feel absolutely that I’ve had a breakthrough ...it was for sure the
flash of a light-bulb experience and that’s why, for me, doing this
twice per week, to have that continuous reinforcement [from peers,
facilitators and now her husband] and because I can recognize
something invaluable that I don’t want to lose. I feel it’s [BA]
allowing me to make the changes I want to make. So, thank you.
BA participants emphasized the importance of a friendly envi-
ronment where their feelings and experiences could be dis-
cussed openly, and this compassionate group milieu
decreased social isolation and increased social support. The
following statement illustrates the importance of social cohe-
sion or connectedness in recovery.
I have a small family, we all live together in the same house and I
know they love me, but they cannot understand the depression, and
I’m having such a hard time being at home. So, this is my safe
haven. I cannot wait to come here, like I said here before, no one is
judging, everyone understands.
The BA therapists also noticed and understood the signifi-
cance of the strong connections or cohesion that devel-
oped among the participants over time and the gains
subsequently made.
I could really see how people were much more comfortable in
connecting and being open about their personal lives, whereas at
the beginning, that wasn’t so much the case. So, I really saw
cohesiveness and kind of a social connectedness, and also, they
were really talking about their goals, they were asking each other
about, “oh so did you make it to the gym last week?” and that kind
of thing, like asking each other and challenging each other a little
bit. So, I think that was adding to that reinforcement that we’re
trying to do in the group.
Acceptability—the Structure, Frequency, and Content
Participants suggested that there were several components of
the BA intervention program which contributed to their
improved mood, functioning, and social cohesion, including
the frequency of the sessions (twice per week for 2 hr), the
structure, and the content of the sessions. These factors con-
tributed to the acceptability of the enhanced BA program and
are illustrated in the following statements.
For me, the way it is structured currently is effective because it
kind of splits the week in half, and I need that refocusing every
three days, and with that, even though, it seems rigorous, and yeah
even overwhelming, it’s bringing things together for me. The dots
are starting to connect, all the different topics [session structure
and content]. It’s like, ‘Whoa, not only do I have this tool, now I’m
finding this tool works well with this other tool in dealing with this
[depression].
It feels like mental sit-ups. If you only do sit-ups once a week,
you know you aren’t going to get anywhere.
A major component of the structured BA group was to
encourage all participants to plan and complete goals outside
of the sessions (homework). The participants chose for them-
selves their specific and individualized goals rather than having
facilitator-generated goals. This provided an opportunity for
collaboration with peers and facilitators when considering per-
sonal goals; this opportunity contributed to a sense of team
collaboration as well as promoting autonomy. BA participants
stated they found the homework practice between sessions
beneficial, as it helped them identify and work on specific
issues and to apply the new skills they were learning into their
“real life,” which supported increased activities or functioning.
I noticed that the homework is what helped me. We are doing
worksheets daily. It’s actually helped me stay focused on the pro-
gram. It helps me to see patterns. I personally enjoy it because it’s
changed patterns in my own personal life.
In contrast to the BA group, we received markedly negative
feedback from the peer support group, despite having the same
frequency of sessions and much more opportunities for group
interaction given the unstructured nature of this group. The
peer support group was designed to have a peer-led structure
with group members initiating and leading the discussion with
minimal facilitator intervention. The majority of support group
members expressed frustration with the unstructured approach
and requested more structure from the group facilitators. Many
reported the sessions were a waste of their time. Two individ-
uals noted that while they would rather have a structured group,
they still found value in the free-flowing sessions, as it was an
opportunity to hear from others experiencing depression.
One noteworthy challenge with the peer-led format identi-
fied by all participants was that it was difficult for them to
generate topics and lead conversations, due to the lack of ini-
tiative and low motivation that characterize depression.
It’s kind of hard to put the onus or the initiative for people that have
depression, but I mean like if I don’t do the dishes at home, I’m not
going to necessarily drive the conversation [here] either. There are
O’Neill et al. 5

some weeks that people don’t say anything. They just listen, but
they won’t contribute. Again, asking people who are unmotivated
to be motivated to make change. Talking about it, but not actually
getting it done.
Surprisingly, the structure of the BA sessions (with less actual
time to talk and interact freely) was found to encourage even
nurture group cohesion or connectedness. Meanwhile, the
unstructured peer support group did not report feelings of group
cohesion or connectedness. This finding was triangulated
through participant and facilitator report and observation by
the interviewers during focus groups. Researchers observed
significant differences in group dynamics, attitudes, and mood
between the BA and peer support groups. On entering the peer
support focus group, we observed participants sitting quietly,
waiting for us to begin the focus group. There was no discus-
sion between group members, and the mood of the room was
subdued, even gloomy. In contrast, when we entered the BA
focus group, the participants were chatting loudly with each
other, laughing, teasing each other, and the mood of the room
was very upbeat. During the BA focus group, the laughing,
teasing, and camaraderie continued and is apparent in the
transcript.
Initially, we wondered if a twice-weekly group in the
morning would result in reduced attendance in both groups
due to the nature of depressive symptoms (reduced motiva-
tion, fatigue), but this was not found. Further, the findings
suggested that the frequency of attendance was not a factor
in improved mood noted by BA participants, as the same
finding was not noted by attendees of the peer support group.
The key elements in the effectiveness and acceptability of the
group BA program included twice-weekly structured sessions
led by facilitators and a format that encouraged patients to
share personal struggles. Meanwhile, participant contribu-
tions and sharing fostered group cohesiveness and led to sup-
port from peers based on a shared understanding of their lived
experiences with depression.
Flexible and Client-Centered Approach
Client-centered programming was important to the research
team because it contributed to ethical research, positive patient
experiences, and improved outcomes. We worked toward cre-
ating a client-centered intervention by repeatedly soliciting and
integrating feedback from participants and adapting the inter-
vention correspondingly. Through this iterative process, we
were able to accommodate the diverse needs of the participants.
Participants in both groups were somewhat diverse in terms of
sex, age, educational background, employment history, house-
hold income, ethnicity, and physical ability.
Two of these factors, physical ability and age, were identi-
fied by participants and facilitators as characteristics that
altered the needs, interests, and capabilities of the BA group.
The flexibility of facilitators to adapt programs in real time to
meet the needs of patients proved more successful when it
came to physical limitations than with age differences,
highlighting the challenges in providing truly patient-
centered care in a group format.
The facilitators of the BA group successfully adapted activ-
ities to accommodate the physical limitations of group mem-
bers, which included chronic pain, fibromyalgia, osteoarthritis,
herniated discs, chronic obstructive pulmonary disease, carpel
tunnel syndrome, and chronic sleep disorder. To accommodate
the needs of the participants, the BA facilitators adjusted the
planned program of activities including the team building
activities, the active problem-solving games, and the two group
outings. The initial plan was to incorporate adventure therapy,
such as a ropes course and so forth, but it was quickly apparent
that this plan would not work for the participants: “You have to
be flexible, right? We talked about the ropes [physical activity],
we can take certain people out on the ropes course but if there
are walkers [assisted walking aids] it’s not happening.” The
facilitators were open to the challenge of adapting their planned
activities to suit the needs of the group members while still
remaining true to the tenets of BA and were gratified by the
positive response from participants:
...in the team building part there was a man who has a number of
physical limitations and he was actually quite impressed by being
able to go out and work with people [the group members]and
communicate. The activity wasn’t overly strenuous and it turned
out to be a lot of fun for him.
While facilitators were able to make some successful adapta-
tions, they were challenged to accommodate the age differ-
ences between participants. One person in the BA group was
28 years old and made several comments to his therapist during
individual sessions about not wanting to end up like the rest of
the people in the group. He also stated that he didn’t feel a
strong connection to the other group members, as he is in a
different stage of life. He told the therapist, “I want something
different in my life. I don’t want to be sitting here at 50-
something talking,” and the therapist stated, “I think that he
really felt alienated.” With the support of his therapist in indi-
vidual sessions, he did continue to set and meet his personal
goals, but there was ongoing concern he might drop out of the
group. This challenge was also acknowledged by his group
peers with comments such as, “Twenty-five year olds would
get bored in this group, as they are at a different life stage-
I’m 65 and I’ve had hard times they may not understand.”
Feasibility—Logistical Lessons for Future BA Groups
Both groups supported the practicality of frequency, time of
day, session length, and length of the group intervention. The
twice-weekly 2-hr sessions were held on Mondays and Thurs-
days from 10 a.m. until noon with a 15-min break in the middle.
This timing and frequency was acceptable to participants. Par-
ticipants reported that a morning group helped them to get up
and out of the house, and their commitment to the group, peers,
and research study was a motivator to do so. There were no
concerns with the burden of twice-weekly attendance, likely
6Research on Social Work Practice XX(X)

because none of the participants were currently working due to
their MDD. The BA group also reported that meeting twice
weekly, the homework practice, and their relationships with
their peers helped keep their focus on treatment and provided
accountability in terms of working on and completing their
stated goals. Meeting twice-weekly encouraged participants
to remain focused on their goals and on making behavioral
changes. One participant referred to the BA strategies as
“mental calisthenics,” and the group agreed that once per week
would be insufficient. Participants in the peer support group
shared consistently negative feedback about the format but
maintained consistent attendance, attributing their motivation
to a commitment to the research study and future patients:
I feel privileged to be a part of the group [research study]. I’m very
appreciative and I’m just looking forward to making a difference
for myself and for others.
Overall, the BA material appeared to be suitable and applica-
ble to all participants despite varying education levels. During
the first focus group, many of the BA participants reported
that the pacing of new information or learning needed to be
slowed down, as “there is a lot of content and it feels a bit
rushed at times.” This feedback was given to the facilitators
who identified the challenge of balancing the participants’
desire for information (asking questions) and an opportunity
to discuss, review, and process their experiences and progress
(supporting group cohesion). The facilitators accepted this
feedback and adjusted the pace of sessions, while at the same
time keeping the core BA principles (values, goals, setting,
and scheduling) to the forefront. The following comment
highlighted this dilemma:
Certainly we want to work on understanding better what their goals
are, their activity schedules, connections between activities and
mood—doing a quick go around [homework review] and getting
something from everyone, but it is so time consuming that it would
often delay the new learning—and this is so the core of BA that if
we don’t get it right early on, then it’s harder to apply the other
principles.
Discussion and Applications to Practice
MDD is a global health-care problem and is the leading cause
of disability (WHO, 2004, 2012). While effective treatments
exist, these options have proven to be expensive and of limited
benefit to many individuals. In contrast, BA is professed to be
easier to implement, exportable, and cost-effective (Dimidjian
et al., 2006; Hopko, Lejuez, LePage, Hopko, & McNeil, 2003).
Since the mid-1990s, BA has been suggested as a stand-alone
treatment for depression (Jacobson et al., 1996). The evidence
for its effectiveness when compared to other treatments has
been debated in the literature with a Cochrane review, suggest-
ing larger samples with improved reporting of design are
needed (Shinohara et al., 2013). Evidence about the effective-
ness of BA so far typically focuses on individual BA, with few
studies examining the utility of a group format. This pilot study
is part of a larger mixed methods trial addressing this gap in the
research literature.
Outcomes from the BA group suggested it is effective and
beneficial. This substantiates the promising results of other
research into the delivery of BA in a group format (Houghton
et al., 2008; Porter et al., 2004; Wesson et al., 2014). Many
participants in the BA group described improvement in their
mood and functioning, which they attributed to the structure,
content, frequency, and social cohesion. Mental health out-
comes also included increased social supports (both peer and
family), increased humor, and an increase in goal setting and
completion of planned activities. The compelling social cohe-
sion that quickly developed among the group is particularly
relevant, given that depression usually leads to social isolation
and limited social supports, which further produces feelings of
depression and loneliness. These withdrawal and avoidance
behaviors are thought to exacerbate depressive symptoms
(Jacobson et al., 2001). The social cohesion observed in this
study supports the suggestion that social interaction in a BA
group may serve as a positive reinforcer in its own right (Porter
et al., 2004). We would argue that this social cohesion was
nurtured in a structured but flexible approach that encouraged
the developing and completion of individual goals as group
members acted as supportive coaches. In some ways, it might
be said to have encouraged a built-in compassionate peer
accountability system.
This pragmatic study demonstrated that a flexible and
client-centered version of group BA for depression can be suc-
cessfully delivered to a patient population with high rates of
severity, chronicity with lengthy psychiatric histories, physical
disabilities, and lower rates of employment. The client-
centered approach likely led to greater uptake and acceptability
of the BA protocol. Perhaps a rigid adherence to the planned
BA protocol would have negatively impacted uptake and
acceptability and may even have impacted mood and function-
ing outcomes. BA, similar to CBT, is a structured protocol-
based treatment that uses worksheets (Martell, Dimidjian, &
Herman-Dunn, 2013; Soucy & Provencher, 2013). According
to Martell, Dimidjian and Herman-Dunn (2013), this structure
ensures that the client and therapist stay on track, while at the
same time, the therapist’s style is validating, collaborative, and
nonjudgmental. Participant and facilitator feedback clearly
indicated the value of the structure and content of BA, while
also prioritizing flexibility and adaptation of the intervention.
Facilitators addressed participant feedback and adapted the
content to meet the needs of participants with impaired func-
tioning due to physical impairment and severe MDD but also to
accommodate the participants’ desire for group discussion and
sharing. The tension between fitting in the planned content, in
particular the core of BA, and the conversations generated by
the content is a challenge likely experienced in other structured
therapy groups and requires facilitator flexibility to address.
Despite a commitment to adaptation and client-
centeredness, facilitators were challenged to address age dif-
ferences in this group format intervention. This difficulty may
O’Neill et al. 7

persist in future RCTs. However, when BA is provided in
clinics, it is possible to address this issue by ensuring that there
is more than one younger person selected for a group, hopefully
allowing the younger members to form a relationship that leads
to improved attendance and group cohesion. Given the com-
ments from the younger BA participant and from the older
participants who bonded over shared life experience, therapists
developing BA groups may wish to select group members
based on similar age and life stage.
Implications for future research include the need to consider
the type of comparator group selected. The use of a peer-led
support group as a comparator confirmed that the frequency,
time, or length of the sessions was not the main contributing
factor in improving mood and functioning. Interestingly, it was
through seeking participant feedback via qualitative data
sources that we unexpectedly discovered that the peer support
group format was negatively impacting the mood of many of
the participants. While this may have been observed when
examining quantitative data sources, such as the Beck Depres-
sion Inventory II scores, the richness of the qualitative data
illustrated the significant problem with unstructured peer-led
groups in a population of patients who are chronically and
severely depressed. The differences between the two groups
were so stark that the clinical and research team has opted to
use a wait-list group as the comparator for the main trial. Given
the effectiveness of the BA group and requests from the com-
parator group participants, they were offered a BA group
immediately after this pilot study concluded. Recent research
has suggested that choosing an appropriate comparator group
for behavioral and social science RCTs is critical to provide
true intervention effects and most trials fail to provide the
rationale for their selection of a comparator group (Wang
et al., 2017). The findings of this trial clearly indicated the
importance of changing our comparator group, which called
our attention to the need for careful selection of a control group
in this particular population.
It is important to acknowledge the limitations of our study.
First, our sample may be subject to selection bias. Participation
in our study was voluntary, and it is likely that volunteers differ
significantly from nonvolunteers in clinically relevant factors.
As a result, our sample may not be representative of the pop-
ulation of individuals with MDD as a whole. Additionally, our
sample consisted of participants seeking treatment and thus is
not representative of a nontreatment-seeking population.
Finally, our study was conducted in an outpatient tertiary set-
ting at a hospital that often provides services to patients with
chronic and severe depression. Therefore, it is possible that our
findings may not be applicable to other health-care and non-
health-care settings, where client factors may differ. However,
despite these limitations, it appears BA in a group format is a
promising evidenced-based practice that will be researched
further in our main RCT trial of this mixed methods study.
Despite the aforementioned limitations, our study used rig-
orous methods to explore the effectiveness, acceptability, and
feasibility of a BA group intervention for depression. Our itera-
tive approach to soliciting and implementing feedback from
participants was appreciated by the participants in both groups,
and the logistical lessons learned will be taken into account for
the main trial. This approach substantiated the work of other
researchers in health care (Lawton et al., 2013; Van Eyk &
Baum, 2003) who encourage patient participation. Lastly, we
wish to acknowledge the lived experiences of participants and
the importance of listening to their voices when shaping our
main trial and other future research. The values inherent in the
social work profession promote social work practice and
research that is inclusive and supports client determination
through listening to client voices and expertise. More gener-
ally, if we purport to take a patient or client-centered approach
in health care, it is important that we do listen to patient voices
and address their preferences and concerns when researching
and developing treatment interventions.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: The pilot study
is supported by the in-kind contribution of resources and personnel
from the Mood Disorders Program, St. Joseph’s HealthCare
Hamilton.
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