I have always resented commercials that urge us to "just do it." For people with depression, it's insulting — and useless — because the smallest task can seem like a huge obstacle.
There are many times in life when moving forward requires discomfort. Transitions from middle school to high school to college, or from one job to another, challenge us to master new skills. But people with depression sometimes have a tougher time during these periods. This is not because they are less capable than others. Sometimes, it's because they have less confidence than the average person. Or they may have a talent for imagining the worst.
With the right kind of coaching, encouragement and education, however, action may be pretty effective treatment for depression.
A frequently cited study of the effectiveness of this treatment was done at the University of Washington and published in 2006. Psychologists compared four types of depression treatment: behavioral activation, cognitive-behavioral therapy, an antidepressant medication and a placebo pill. They assigned about 250 people with major depression to one of the four treatment groups. After four months, patients in the behavioral activation (BA) group did at least as well as those receiving an antidepressant. In one way, BA was better than antidepressants — fewer patients receiving BA dropped out of treatment than those taking a pill. Also intriguing: among the most severely depressed patients, BA was more effective than cognitive therapy.
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What is Behavioral Activation Therapy?
Behavioral activation is not a practice of ordering patients to do something. It is, however, a technique that helps depressed people do what they tend to avoid.
Proponents of this type of therapy believe it works because depressed people tend to withdraw from stressful situations. They get some relief in the short run because they spare themselves the pain of confronting tough problems. But they also miss out on the rewards. For example, a depressed man may call in sick to avoid an unpleasant interaction with a co-worker. In the long run, however, he misses out on the satisfaction that could come from getting his job done and earning a living. And avoidance leaves the original problem unchanged. Inaction just makes problems worse and deepens depression so that getting out of bed in the morning becomes more difficult.
Logic is the tool used in Behavioral Activation Therapy, not shaming or blaming the person for his problems. Depression usually makes people withdraw from activites that could be pleasurable, depriving a person of the satisfactions (environmental reinforcers) that come from engaging in life. So activity can help increase enjoyment in life and relieve depression. To encourage activities, patients are taught to keep to a daily schedule and gradually increase their activity. The therapist also tries to help the patient interrupt the circular, self-critical thinking associated with depressed feelings and pay attention to the present moment and actions that help them reach their long-term goals. Improving problem-solving skills makes up the third part of BA.
Behavior therapy and cognitive therapy differ in important ways. A cognitive therapist will spend time reviewing negative and distorted thinking and self-defeating beliefs. According to the cognitive therapy model, thinking must change before behavior can. A behavior therapy model such as the BA technique asks the patient not to think too much. It focuses on simple strategies such as goal-setting, problem-solving, and attending to the task at hand, rather than on the overwhelming big picture. The two approaches have been closely linked for many years through the approach called cognitive-behavior therapy (CBT), which purposely blends the two.
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Prescription for Action
A happier life does not depend on a victory of "just do it" over "getting in touch with your feelings." The answer, as usual, lies somewhere in the middle. You don't want a life of grinding through tasks without feeling anything. The strategy is to turn your attention away from thoughts and feelings that undermine your functioning, and toward thoughts that promote it. Proponents of behavioral activation ask their patients to notice when they are dwelling on unproductive thoughts and focus instead on the immediate sights and smells they're experiencing around them. Once you begin to function better, it's easier and more useful to begin to examine your thoughts from a position of strength and understand why they were so negative in the first place.
Taking action is not easy for a depressed person to do on his or her own. So a therapist has to be the encouraging coach or personal trainer who reminds a patient of the good that will come from doing difficult things.
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Putting it All Together
Behavioral activation should not replace CBT, antidepressant medication or any other reasonable treatment as the first approach to treating depression. But BA therapy techniques are worth including in a comprehensive plan for treating depression, especially when depression is severe.
In practice, you don't have to choose one technique over the other. You can use whatever you need. Research on depression treatment has shown that combining approaches gives patients the best chance to feel better and do better. For most people, behavior activation, as a method, can be added into a mix of psychotherapy methods, along with the judicious use of antidepressant medication. In other words, don't "just" do it. Instead, give all of it a try.
Dimidjian S, Hollon SD, Dobson KS, et al. "Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression." Journal of Consulting Clinical Psychology. Aug 2006;74(4):658-670.
Michael Craig Miller, M.D. is Editor in Chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for more than 25 years and teaches in the Harvard Longwood Psychiatry Residency Program.