Forging a Connection Between “Doing” and “Feeling”: How Behavioral Activation Therapy Can Alleviate Depression

 

By Lauren Tanabe, PhD

 

A few weeks ago, I stumbled across a short description of a recent study published in The Lancet out of the University of Exeter: researchers found that behavioral activation (BA) therapy works as well as cognitive behavioral therapy as therapeutic intervention for depression. Cognitive behavioral therapy (CBT) has been previously shown to be as effective as antidepressants.

 

According to the Society of Clinical Psychology, depression may cause people to “disengage from their routines and withdraw from their environment.” Over time, this isolating avoidance behavior can intensify depression as people “lose opportunities to be positively reinforced through pleasant experiences, social activity, or experiences of mastery.” Behavioral activation therapy aims to alter the patient’s avoidance behavior by increasing exposure to “sources of reward.” As well as by helping people to understand the connection between their behavior and their mood.

 

In lay-terms, activity will influence how you feel. If you sit at home alone, this may worsen depression. If you coax yourself to engage in some kind of social activity, or to work towards a goal (chores, hobby, work), this may lessen depression symptoms.

 

This seems straightforward enough. When I first learned of the study, scrolling through a blurb in Scientific American entitled, Depressed? Do What You Love, I must admit, I audibly scoffed, Really? We need a study to tell us this? At the time, it seemed rather obvious and mostly common-sense that doing what you love would lead to feelings of happiness (or if not happiness, a lessening of depression). I reached out to the lead author on the study, Dr. David Richards of Exeter University and proceeded to pose question after skeptical question. Dr. Richards patiently and thoroughly answered each one. I was most curious about how he would respond to one question in particular:

 

Some might say that it’s not surprising that doing what you enjoy can ward off depression. Why do we need a study to tell us this?

 

“If it were that obvious, then why would we have got to the point of recommending complex therapies like CBT [cognitive behavioral therapy] which focus on changing the way we think? Or why wouldn’t people have figured it out for themselves? … BA is not just doing what you enjoy. It is increasing the opportunities for positive reinforcement and reducing avoidance caused by aversive experiences. Depression is self-reinforcing and before you know it you can find yourself in a position where you cannot see a way out, just by having started on what at the time seemed like a sensible path of avoiding things you don’t like. Although there is an element of the common sense to BA that you suggest, in actual fact people often get stuck and what BA does is help them make some important connections between activity and mood which then leads to a personalised programme of re-activation …

 

As I read his email, my emotions ranged from incredulous to enlightened.  I mulled over his words in the following days. Perhaps, like most who suffer from depression, I want to believe that I am actively doing what I can to wriggle my way out of its clutches. Especially since it often takes an inordinate amount of effort and cognitive calisthenics for me to admit to myself (or anyone else) that I need help in the first place. I’ve painstakingly evaluated my thoughts and actions with a therapist and I know in great detail why I’m depressed. I’ve finally filled that antidepressant prescription, that old, familiar frenemy I hate to get in touch with again, after so many independent years. These actions should be enough to cure me. And yet, each morning, as I wash down my pill, vicious thoughts gnaw into me for being weak, followed by the washing over of a listless acceptance in the belief that I am broken, followed by the eking seepage of a meek hope. That tiny bit of hope – that these tyrannical thoughts will dissipate and I’ll finally be free – carries me through the day. The daily ritual of self-flagellation even (especially) for seeking help is simply exhausting. So, maybe there is something more I could be doing to help myself.

 

Dr. Richards went on to write, “Western tradition often stresses that if we are ‘ill’ we must cure the sickness inside us before taking our place in the world again. What BA does is tell people that they do not need to do this. So although you might think that is common sense, you would be surprised at how many people are applying a ‘fix me first’ principle and are surprised by the BA rationale …”

 

Behavioral activation therapy highlights a subtle, yet significant, shift in how treatment for depression is viewed, in general. A common analogy used in describing this type of therapy is that it works from the “outside-in” rather than the “inside-out.” That is, if you’re depressed you don’t wait to feel better and then participate in fulfilling activities (a common and somewhat intuitive strategy). Rather, the participation in meaningful work will alter your outlook and mitigate the depression. This, I could relate to.

 

I could recall myriad examples of times when I knew that sitting on the couch and binge-watching bad TV or going to bed at 7 pm was not going to lead to fulfillment of any kind, and much more likely just make me feel worse about myself, but I did it anyway. Why? Likely a strange dichotomy of wanting to make myself feel better from a quick-fix of escapism coupled with a twisted hatred of myself – I couldn’t possibly excel at anything other than existing as a gluttonous zombie, so why bother? And then, of course, there is not wanting to be a burden to others or to bring them down. Practicing self-imposed isolation in order to avoid becoming the archetypal “Debbie Downer” feels necessary to preserve relationships and save face.

 

But, clearly, this approach doesn’t work for most. It certainly didn’t for me.

 

The Exeter study was a well-controlled, randomized analysis of over 400 men and women who either received CBT or BA therapy. One year after treatment, both groups reported at least a 50% reduction in symptoms and were equally likely to experience remission. Both groups also contained some participants already taking antidepressants (ADs).

 

I asked Dr. Richards if he thought that being on medication could make someone more receptive to the therapy. He did not believe so, “We stratified the randomisation to ensure both groups had the same likelihood of being on ADs. The key thing is that for most of them, the drugs had not worked, evidenced by the fact that they had been on them for a considerable while before starting BA. We chose this because this is the reality of clinical services – psychological therapists have to work with patients who are on tablets as well as undergoing therapy. It’s the real world.”

 

The real world is replete with people suffering from depression (approximately 350 million worldwide). Of those, many do not have access to adequate treatment. According to the study, BA therapy is a more cost-effective option (about 20% less expensive than CBT), as treatment can be delivered by less specialized health workers. This is important. Wide-scale treatment options are critical, especially in low income countries where the treatment gap can be as much as 80 – 90%.

 

When I first read about BA, I mistakenly thought the goal was to do what makes you happy. But this is not the case. I asked Dr. Richards about this: “It’s not at all about making you happy. It’s about the function of behaviour in the short- and long-term. People learn to see the connection between activity and mood and choose activities where their experience is that this will be a more positive experience – achieving things, reducing avoidance.”

 

When asked why he believes BA therapy works, Dr. Richards responded, “It is because what we do has a profound connection with how we feel. Experiencing this connection is the core.”

 

I think I’ll be adding aspects of BA therapy to my current repertoire. As much as I sometimes want to avoid others, I’ll make the extra (albeit sometimes painful) effort to socialize with friends and to engage in tasks that “rational me” knows will lead to fulfillment (even if “depressed me” fights it). It will be a slow process, but no better time than the new year to forge new habits, new behaviors, and hopefully, resurrect a happier version of myself.

Happy Science: Turn That Frown Upside Down

 

By Lori Bystrom, PhD

Although 2016 may have been rough for some, most of us are still optimistic about 2017. We all want to start the New Year happy. Fortunately, more and more businesses, institutions, and even countries and cities are focusing on happiness. Companies, such as Happy City in Bristol, England, aim to keep people content. The Center for Health and Happiness at Harvard is gaining a lot of interest (see The Atlantic  article). Many countries and cities are being ranked based on happiness (check out the happy planet index). And just look at the United Arab Emirates, which appointed its first “minster for happiness” early in 2016. All of this sounds wonderful and promising, but what about the happiness of scientists?

 

I am not sure that many people would equate “science” with “happiness.” As an academic scientist, I recall happy moments of scientific discovery, but those are memorable partly because they are rare. I particularly recall one glorious moment during the last month of a project — after many failures and nearly passing out — when I was finally able to get publishable results. Oh how long I waited for that happy day!  More often, however, the scientific work environment can be tough, especially in academia, with little positive feedback, low pay, and competitive/high pressure work. This is all compounded with constant trials and tribulations of everyday science, all of which can take a toll on the mental health of scientists.

 

It may seem grim to view scientific work as so difficult, but this does not stop many scientists from loving science. In fact, I think science would probably be very boring if amazing results were so easy to achieve all the time (well, it would be a little bit exciting). I think many scientists would agree that there is something appealing about the challenge of discovering and exploring the unknown in order to reach that happy eureka moment. That being said, though, science research does not need to be as depressing as it is. This is to say: there is much that could be done to make scientists less unhappy.

 

So what can be done to make or keep scientists more content with their job? More money is always nice, of course, but this is not always the answer, nor is it always feasible. There are, however, other approaches that may improve work conditions for scientists. Here are a few ideas for promoting happiness in the lab, especially for academic scientists.

Listen to all; respect all

This may seem obvious, but this was often a major problem in the labs where I have worked.  I think it is always good to listen to what everyone has to say about a project. I have witnessed people at all levels in the academic institution fail to encourage this kind of healthy discourse. Everyone should have a voice. Not only that, but scientific discovery comes in many shapes and forms. Even a young scientist may see something that a more experienced scientist might not, because they are too lost in the detail. Different perspectives may help shed light on problems that initially seem too complex to solve.

 

Excluding people from intellectual discussion hinders the creative flow in research and leads to unhappy scientists. Most researchers would like to provide some feedback about projects in the lab.  Scientists should not be treated like robots. This   only makes scientists angry. And once a few colleagues are upset, they are liable to take it out on everyone else, leading to a lab infested with unhappy scientists.

 

Define and communicate expectations

All mentors should have their students and/or employees define what kind of expectations they have of each other at the beginning of a project. These expectations should be reviewed over time, as they will likely change. You may not see eye to eye with your mentor, but they are also not mind readers. This is why expectations from both sides should be reviewed. And if you are not a good match then it is better to find out early.

 

In addition to short-term goals, both mentor and mentee should also define their long-term goals. Not everyone wants to go to medical school, be a PI/advisor, or stay in the lab, and therefore scientists should work on projects that are relevant to their long-term and short-term interests. Furthermore, if you need advice you should ask, and if someone asks for advice, you should respond. No one has a crystal ball and so dead silence does not help anyone. Ultimately, good communication prevents miscommunication and an unhappy lab environment.

 

Aim to achieve little goals

It is not reasonable for everyone in a lab to expect to be the first author on a paper in a high-ranking journal after a short stint in research (I have had many summer students expect this!) For this reason, I think it is important for scientists to aim for small goals, especially at the beginning of a project or career. By starting out small you can build a strong foundation for a big project. For students that are new to a particular field of science, or even science at all, it may be good  for them to work on projects already in progress by developing small and relevant side projects, as well as providing them small incentives (e.g., name on poster or something that they can put on their CV). This way there is less confusion in the lab and the outcome of the project is more likely to keep everyone happy.

 

More senior scientists can also benefit from taking on smaller projects within or outside of their own research. This can help because many scientists may not see the light at the end of the tunnel when their project is not working as planned. In such an eventuality, having smaller projects on the side allows them to take a break from their main project by using their expertise in small doses to help other projects, especially those close to being finished. This, in turn, may help them better visualize their problem, keep their publication record up, and boost their morale.

 

Keep everything organized and transparent

I think organization is crucial in a lab. This not only pertains to cleaning the lab space, decluttering lab supplies and maintaining instruments, but also to finances. It would be nice if someone at the institution other than the PI had to deal with this. Unfortunately, this is not usually the case. It is a lot to ask that one person manage research, lab drama, and also lab finances. I find that academic scientists (myself included) are not trained how to do this very well. Therefore, it may be good if everyone in the lab sat down and discussed what is needed for various projects in order to make sure the money is well spent. If financial conditions are becoming a problem in lab — as they often are, even in the most prosperous labs — it may also be good to have everyone write a budget for their project. Transparency about the financial situation of the lab also helps people understand the state of the lab (and perhaps the mood of their PI/boss), and may encourage scientists to think again about paying extra for something not necessary (do we really need pink pipettes?). A lab that is organized and financially transparent helps prevent unnecessary stress and avoids a lot of unnecessary resentment.

 

Don’t forget to socialize… and take a break!

I know that I could not have survived my lab experiences without the support of other fellow scientists. I found that lunchtime was something I looked forward to every day because not only could I eat (nom nom), but I could vent about experiment problems, laugh, or learn from other colleagues. I think all mentors should encourage this and celebrate any scientific achievement with some kind of social event, even if it only occurs during lab meeting. A friendly and social environment makes for happier scientists.

 

Additionally, overworking scientists leads to less efficient and productive work. Before a big deadline is about to approach, it might be good for scientists to take a few hours off to recompose themselves. This might be a good time to take a walk or eat a nice dinner. Otherwise, if there is no time for that it might be good to take a longer vacation after the deadline is over so you can come back more refreshed and ready to tackle more challenging moments in science. I know I have denied myself vacations many times because I thought maybe if I just kept on working I would get the data I needed sooner. Unfortunately, this often led to less productive work. This is why it might be good to enforce that all researchers take vacations, especially after stressful periods.

 

Perhaps in the future, there will be organizations to help manage the happiness of scientists, although I am not holding my breath for something like this to appear anytime soon. Maybe the first step, however, is acknowledging that there is a lot of unnecessary unhappiness in the lab and that we should try to do something about it. The future of science will be better if we keep scientists smiling 🙂

Goals and Habits: A Scientific Take on New Year’s Resolutions

 

By Gesa Junge, PhD

Happy New Year! Did you make any New Year’s Resolutions? Are they exactly the same ones as last year? Maybe science can help you actually keep them this year (so you can make new ones for 2018).

Giving up on New Year’s Resolutions is incredibly common. Statistics suggest that about half of us make New Year’s Resolution, but less than 10% keep them. Still, there are some ways that psychologists, behavioral scientists and even economists suggest can help you actually make some lasting changes.

Setting the right goals is an important first step. There is a whole TED article on the science behind goal-setting, but the key issues are to pick a meaningful goal, and figuring out exactly why it is so important to you to make this change in order to stay motivated. Also, goals need to strike a balance between too easy and too hard – research from the 1980s shows that more difficult goals can make you work harder. Similarly, specific goals lead to better outcomes than vague and generic goals, probably because it is easier to measure success.

But realistically, in order to make long-term changes, you need to change your habits. Neurologists distinguish between goal-oriented and habitual actions, and according to a 2006 study, almost half of our behavior is habitual. Routines allow our brains to function more efficiently. This makes sense – if we had to focus on all the little actions that are required to for everyday things like making a cup of tea or taking the subway to work, that would be incredibly exhausting.

So a lot of processes can become automated, often even without you noticing. Studies show that rodents trained to find a food reward in the left arm of a T-maze will quickly get into the habit of running straight down to the left arm even if the reward is no longer there. The basal ganglia are thought to play a key role in habit formation, although there is still some controversy around which brain regions are specifically responsible for habit formation. NIH researchers found that, on a molecular level, the endocannabinoid system plays a role. Endocannabinoids are endogenous signalling molecules that stimulate activity via cannabinoid receptors, and mutations in the CB1 cannabinoid receptor prevented mice from forming habits in a lever-press test for a sucrose reward.

As we probably all know habits can be pretty difficult to change. Researchers at MIT trained rats to turn left for chocolate or right for sugar water in a T-maze, depending on which one of two audio signals they received. If the rats are later given chocolate milk mixed with enough lithium chloride to make them nauseous, they will still follow the audio cue to the left (even if they did not always drink the milk), indicating the behavior had become habitual. However, this behavior was lost when the researchers interfered with the infralimbic cortex, and the rats soon started habitually turning right for the sugar water, regardless of the sound cue. But once this new habit was broken (again by interfering with the infralimbic cortex), the animals reverted back to the original habit of going left or right depending on the sound cue. This suggests that habits are really replaced as opposed to lost, and that they can come back, which would explain why it is a) quite hard to break a habit in the first place and b) not to fall back into old habits later.

So a good strategy might be to change or replace habits rather than trying to get rid of them completely. In order to achieve this, there are various commitment devices, that is, measures that make you do the things you would otherwise probably not feel like doing. There is a very interesting Slate article that gives more examples, but one that sounds particularly effective is a website called StikK, founded by behavioral economists from Yale. Here, you can formulate a commitment and put money on the line which, if you don’t reach your goal, is donated to a charity, person or – probably most effective – an anti-charity. An anti-charity is a cause you truly despise (think political parties, lobbying groups, sports teams…).

Another interesting tool is “temptation bundling”, essentially combining activities you like to do with activities you know you should do but don’t particularly enjoy, e.g. only binge-watching Netflix while ironing or cleaning the house. This was evaluated in a study at the University of Pennsylvania that showed that allowing people to only listen to engaging audio books at the gym (by means of a locked-away iPod) caused them to spend more time at the gym than control groups. Unfortunately, all the effects were lost after Thanksgiving break, but November is a while away, so maybe it would be worth a try.

So it may take some effort, but hopefully you can find a way to stick to your resolutions longer than last year. Or at least past Ditch New Year’s Resolutions Day which apparently is January 17th. Good luck, and all the best for 2017!