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.