Older Adults’ Experiences of Telephone-Delivered Behavioral Activation with Mental Imagery as a Treatment for Depression During the COVID-19 Pandemic: A Qualitative Study
Abstract
1. Introduction
2. Materials and Methods
2.1. Design
2.2. Participants
2.3. Data Collection
2.4. Analysis
3. Results
3.1. Acceptability of BA as a Concept in Relation to Depression
3.1.1. Diary Increased Self-Awareness
“…the diary was very good because I could see in retrospect what I had done and how many contacts I actually had.”—Woman in her 70s
“I thought the activity diary was very good because I could, like, see what I did all day and how much time it took and how valuable I thought it was or how important it was or things like that. That was how I could see myself, what I had done and why I did it and if there was any value in it. I think it was the best part.”—Woman in her 60s
3.1.2. Activity Planning Made Me More Active
“Yes, I believe that I’ve become more determined, not just saying that perhaps we will do something, but rather ‘tomorrow we will do it.’”—Woman in her 60s
“Yes, I see the activities in front of me and what I’m going to do and feel like “on Friday I’m going to do this and that’ll be fun.’”—Woman in her 60s
3.1.3. Follow-Up Increased Motivation
“And then you got some assignments, that uh, you had to set a goal to do something. …and then you did it, and you had to tell how you had experienced this goal, and activity, and [setting the goal] that is what made it happen.”—Woman in her 70s
“I did those things that we agreed upon, but at the same time I really looked forward to the calls. It really gave an acknowledgement that I could say that ‘I have managed to do this activity because we said so.’”—Man in his 70s
3.1.4. Pandemic Restrictions as a Barrier for Activities
“I feel like activities, that’s very hard to talk about now during corona-times and when I can’t be active, I mean, I can go out for a walk, but I can’t participate in things that I’ve participated in before… For me, activity means being out and meeting people, doing things with others.”—Woman in her 80s
3.2. MI as Motivator or Irritator
3.2.1. MI as a Useful Tool
“Most of what you visualize, makes you succeed at what you do. It’s a matter of finding the positive images of your goals ahead.”—Man in his 70s
“Then it was this mental imagery, with the lemon and all that. If you do it you feel better, you understand it better.”—Woman in her 60s
“First and foremost, when I did this, I thought what is this? I was kind of set on that this will lead to nothing, but then I must say it was very soothing. … That is, I turned inwards, and it felt like a whole different world.”—Woman in her 60s
3.2.2. No Point Using MI
“And the first time I was supposed to imagine holding a lemon, and then cutting the lemon and see what it looked like. And that felt a bit silly actually… It didn’t feel relevant that I should imagine going to the hairdresser or giving away old clothes to charity or looking at a lemon. I think I’m a bit too down to earth for that.”—Woman in her 80s
“Eh it didn’t work so well. I guess it’s hard for me to imagine how something looks, I can’t see it in front of me.”—Woman in her 60s
3.3. Telephone Contact Being Similar to Face-to-Face Contact, but Not the Same
3.3.1. Telephone Reduced Barriers
“In one way I would rather sit in a room together with a person… But to be honest, that would have made the threshold higher, that I perhaps hadn’t been able to follow through.”—Man in his 60s
“The telephone is fantastic! Yes, because many older persons aren’t online and then that’s not an option for them. For them, the telephone is a lifeline.”—Woman in her 70s
3.3.2. Disadvantages with Telephone Contact
“I prefer meeting face to face because… digital meetings and telephone meetings are only about the words… and then you miss out on a big part of the other language, the quiet language.”—Man in his 70s
“It’s always more difficult to talk over the telephone instead of talking face to face… It becomes quite anonymous, you don’t know who you are talking to or… well, I mean, you have a name, but you don’t have a face.”—Woman in her 80s
3.3.3. Adding Face-to-Face Contact Could Improve Treatment
“If it would be possible, if you could have the first meeting face to face, and then the other meetings… A personal contact, a personal encounter cannot be replaced by anything… But then, having the rest over the telephone, that would be excellent!”—Woman in her 60s
3.4. The Importance of Being Seen as a Whole Person
3.4.1. The Need to Discuss Causes of Depression with Therapist
“Perhaps also the causes, why you feel the way you feel… It [the depression] didn’t come out of the blue, of course there are a lot of things behind it.”—Woman in her 80s
“It’s not just covid that’s made me… well you could say depressed or sensitive.”—Man in his 70s
3.4.2. Need for Increased Person-Centeredness
“If it’s possible to widen the treatment to more than just activities… but I’m not sure how to put it… It depends on what experiences you have, but more facts or coaching and… pep-talk or what could I say… Perhaps making the treatment more tailored in some way, see what kind of a person you’re working with so to speak.”—Man in his 60s
3.5. The Power of Being Recognized
3.5.1. Looking Forward to Talking to Someone
“Well, that was good. Because then you had someone to talk to about things and, you awaited that call.”—Woman in her 70s
3.5.2. The Healing Power of the Talking Cure
“The calls were so very good; the therapist was so trustworthy and sensible… For me it didn’t matter that it was by telephone, for me it was about illuminating, that it enlightened me about my thoughts more than I could do by myself.”—Woman in her 60s
“Perhaps there should be additional calls, a bit more than four weeks. I believe it would have been better with additional calls.”—Woman in her 60s
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
COVID-19 | Coronavirus disease 2019 |
BA-MI | Behavioral activation with mental imagery |
BA | Behavioral activation |
MI | Mental imagery |
CBT | Cognitive behavior therapy |
TA | Thematic analysis |
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Interview Guide |
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|
Themes | Sub-Themes | Summarized Findings |
---|---|---|
1. Acceptability of BA as concept in relation to depression | Diary increased self-awareness | The use of an activity diary with daily registrations for one week increased the awareness of the link between behavior and mood. |
Activity planning made me more active | The activity planning was described as a good way of getting activities happen and increasing participants’ motivation to perform the activities. | |
Follow-up increased motivation | The follow up of completed activities according to the activity plan by the therapist was important for making the activities happen. | |
Pandemic restrictions as a barrier for activities | Pandemic restrictions (i.e., social distancing and home confinement) made it difficult to engage in certain activities and was thereby a barrier for activation. | |
2. MI as motivator or irritator | MI as a useful tool | MI was useful in giving focus towards the goals of the activities and provided a deeper understanding of the potential positive effects of the activities. |
No point using MI | MI can be difficult for some and may feel uncomfortable and pointless. | |
3. Telephone contact being similar to face-to-face contact, but not the same | Telephone reduced barriers | Remote delivery via telephone reduced barriers for communication related to pandemic restrictions and made remote contact possible for those without access to Internet. |
Disadvantages with telephone contact | Compared with face-to-face interaction, contact over the telephone felt less personal, and non-verbal communication was lost. | |
Adding face-to-face contact could improve treatment | The telephone-based intervention could be improved and strengthened by adding one face-to-face session. | |
4. The importance of being seen as a whole person | The need to discuss causes of depression with a therapist | Many had thoughts about potential causes for their mood and depression and felt a need to talk about these causes with their therapist. |
Need for increased person-centeredness | It is important to make room for discussions about individuals’ history, personalities and needs, and to be flexible about the time needed for these discussions to make the intervention more person-centered. | |
5. The power of being recognized | Looking forward to talking to someone | Receiving a call from the therapist each week for four weeks felt good and was something to look forward to. |
The healing power of the talking cure | The contact and conversations with the therapists were healing and were an important part of the treatment. |
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Share and Cite
Pellas, J.; Damberg, M.; Renner, F.; Ji, J.L.; Kivi, M. Older Adults’ Experiences of Telephone-Delivered Behavioral Activation with Mental Imagery as a Treatment for Depression During the COVID-19 Pandemic: A Qualitative Study. Behav. Sci. 2025, 15, 807. https://doi.org/10.3390/bs15060807
Pellas J, Damberg M, Renner F, Ji JL, Kivi M. Older Adults’ Experiences of Telephone-Delivered Behavioral Activation with Mental Imagery as a Treatment for Depression During the COVID-19 Pandemic: A Qualitative Study. Behavioral Sciences. 2025; 15(6):807. https://doi.org/10.3390/bs15060807
Chicago/Turabian StylePellas, Johnny, Mattias Damberg, Fritz Renner, Julie L. Ji, and Marie Kivi. 2025. "Older Adults’ Experiences of Telephone-Delivered Behavioral Activation with Mental Imagery as a Treatment for Depression During the COVID-19 Pandemic: A Qualitative Study" Behavioral Sciences 15, no. 6: 807. https://doi.org/10.3390/bs15060807
APA StylePellas, J., Damberg, M., Renner, F., Ji, J. L., & Kivi, M. (2025). Older Adults’ Experiences of Telephone-Delivered Behavioral Activation with Mental Imagery as a Treatment for Depression During the COVID-19 Pandemic: A Qualitative Study. Behavioral Sciences, 15(6), 807. https://doi.org/10.3390/bs15060807