Behavioral Activation for Depression
Image: Biking by Jess Foami (CC0)
Synopsis: Behavioral Activation is a strategy that not only helps major depression but also helps prevent mental illness. The activities and structure of behavioral activation encourage us to have a routine of healthy, uplifting and prosocial behavior. This article explains behavioral activation and how it works.
BY LEN LANTZ, MD / 3.22.20; No. 16 / 8 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.
What is behavioral activation?
Behavioral activation is the process of proactively increasing your activity level of positive activities. Behavioral activation strategies can be traced back to B.F. Skinner’s 1957 book, Science and Human Behavior, and were further elaborated in 1973 in Charles Ferster’s paper, “A Functional Analysis of Depression.” Dr. Ferster wrote, “The critical factor is a fixed and large amount of activity.”
In a 2009 meta-analysis by Mazzucchelli, et al., behavioral activation was shown to be substantially beneficial compared to placebo in the treatment of depression (effect size of 0.87 in 16 RCTs). Behavioral activation can help major depression tremendously and can also be a strategy to prevent mental illness in times of stress and uncertainty, such as the loss of a job, having a child, the loss of a loved one, or other major life transitions or disruptions, including quarantine and social distancing.
Is there a risk to mental health with a lack of structure and activities?
I have heard countless stories from friends, family and patients about the negative impact on their mood after transitioning from a high activity level to a low activity level. Think about the times in your life when your mood crashed after a major accomplishment or task. Shouldn’t you have been on cloud nine? The drop in mood could be related to your life being completely out of balance and feeling exhausted by the time you completed your goal or project, but it also could have been due to moving from a high activity level to a low activity level or moving from a structured, goal-oriented schedule to no schedule at all. You can protect your mental health through behavioral activation.
How does behavioral activation work?
When someone is depressed, they lack energy, motivation and enjoyment, which leads them to stop doing the activities that normally help them feel good. Their resulting inactivity then worsens their depression.
Behavioral activation is about forcing yourself to do meaningful activities that are in line with your values – the things you do when you’re not depressed. When a depressed person puts themselves on a schedule filled with positive activities, they are sending powerful signals to their brain to wake up and function. A busy schedule with cognitive activation makes the brain function in a non-depressed way and stimulates neural pathways that are underactive in depression. And even if someone with depression doesn’t experience as much enjoyment as normal with positive activities, chances are they will feel better than they would have if instead, they had done nothing.
Story: the phone call
While I don’t do this often, there are times when I call one of my patients to see how they are doing. Most of the time when I reach out to a patient like this, it is because we both know that they are struggling and they failed to call me as planned with a progress update. For a severely depressed patient, the conversation might go like this:
DOCTOR (calling at 11 am) Hi, “Sarah.” This is Dr. Lantz. Thanks for picking up my call. How are you doing?
PATIENT (sounds sleepy and irritated) Horrible? What did you think I would say?
DOCTOR Well, at our visit last week we talked about strategies for getting your depression better. I’m following up with you because I didn’t get a voicemail from you yesterday with a progress update. Have you had a chance to start any of those strategies?
PATIENT No.
DOCTOR Okay. Thanks for letting me know. What’s getting in the way?
PATIENT I’m just too tired…
DOCTOR You’re too tired. I understand. It’s hard to do activities when your motivation and energy are so low already. It kind of sounded like I woke you up when I called you. Are you still in bed?
PATIENT Well, yeah.
DOCTOR Okay. You’re still in bed. I know you are tired, but here is the situation that we talked about last week. You cannot stay in bed for a few weeks, go into hibernation and wake up free of depression. That’s not how it works to get rid of depression. The depression is there in bed with you and it won’t go away on its own. Let’s see if we can get you started today on some of the activities that will get you free of your depression. I need you to get out of bed. Would you be willing to get out of bed right now while we are talking on the phone?
PATIENT (Sound of movement, groaning) I’m up.
DOCTOR Great. Now, do you have the list that we developed and that I wrote out for you about the plan each day?
PATIENT Yeah. It’s right here. It says, 1. Get up by 9 am. 2. Make a sign to put on the bed that says “STAY OUT OF BED BETWEEN 9 AM AND 9 PM.” 3. Shower and get ready. 4. Put on clean clothes. 5. Leave the house and select an activity (go for a walk around the block, go get my favorite latte, meet a friend and hang out, go window shopping) and if I don’t leave the house, my backup plan is to play my guitar for 30 minutes and then pick out a book to read.
DOCTOR Awesome! So, you are out of bed and you have the list. Are you willing to start working through this list today?
PATIENT Yeah…
DOCTOR Perfect. What are you going to do after you get ready and leave the house?
PATIENT I’m probably going to get a latte. I need a pick-me-up before I look through my mail today. I’ve been ignoring some of my bills.
DOCTOR Okay. And what are you going to do to reward yourself after going through your mail and bills?
PATIENT I’ll probably play some guitar and get back to my novel.
DOCTOR That sounds like a good plan. So, I have you scheduled to see me again on Monday at 10:30 am. Do you have me on your calendar?
PATIENT Yes, it’s there. Thanks for calling me. See you Monday.
Does having a job or going to school count as behavioral activation?
While there can be both positive and negative effects of going to work or school, I do think that going to work or school is a form of behavioral activation. It can increase stress/anxiety but it also often helps depression. This is part of why I try to get my depressed patients back to work and school as soon as possible. Work and school can:
Put people on a schedule
Make them get up and stay out of bed
Cause them to use their brain to accomplish tasks
Increase social connectedness
Distract from negative thoughts
Enhance safety (reduce the risk of suicide) by increasing social contact
Provide meaning through learning and contributing to others (projects, groups, communities)
Result in the reward of a paycheck or satisfaction of improved grades
Are mental health days healthy?
Sometimes people want to take a mental health day from school or work. In reality, mental health days can be good or bad. If your idea of taking a mental health day is staying in bed all day, then doing so is probably a bad idea. Most people who stay in bed or on a couch in their pajamas all day feel worse, not better. Make sure that you don’t use your mental health day to feed your depression. Instead, use your mental health day for positive, creative activities and catching up on things you need to get done. These kinds of mental health days are healthy and restorative.
Components of a good behavioral activation strategy
The best strategies involve scheduling many activities with variety. Start by forcing yourself to do the things you would normally do when you were not depressed. These are activities that you enjoyed in the past or that you would do to charge up your batteries. If you are depressed, you may not enjoy these activities as much as when you were depression-free, but they will still help.
Begin by getting up and getting ready in the morning. Get exercise and do creative things. Do some necessary tasks around the house and then leave the house. Don’t make decisions about what to do based on how you feel. Make a rational, not emotional, decision about whether you are going to do an activity or not. Make decisions that are in line with your values. When adding activities to your schedule, try to broaden your range of activities, maybe including things that are opposite ends of the spectrum or engage all of the senses (sight, smell, touch, taste, hearing):
Social and Solitude
Nature and Indoors
Art and Puzzles
Playing music and listening to music
Physical activity and meditation
Entertainment activities and meaningful service
20 activities to consider when you design your strategies
Go to the gym before you go home from work.
Limit naps to less than 1 hour per day.
Go for a walk in nature.
Call a friend.
Think of tasks you have been putting off. Pick the quickest, easiest one to complete and do it.
Draw a picture or doodle.
Turn on the radio and find the station that you like the most.
Play your favorite song and sing along with it (no matter how good or bad you are at singing).
Go to a hot yoga class (no matter how fit or inflexible you may be).
Go to a coffee shop, sit down and savor your drink.
Think about a social issue you care about and call someone related to that cause. See what simple opportunities there are to volunteer.
Go to a movie.
Go to a museum.
Visit a flower shop or a greenhouse.
Go and listen to live music.
Plan for a visit to a new restaurant or get take-out.
Complete a puzzle, sudoku or crossword puzzle.
Download a podcast on meditation or mindfulness, listen to it and follow the cues.
Do a physical activity you haven’t done in a while: ride a bike, hit a tennis ball, kick a soccer ball, go cross country skiing, go swimming, hit a golf ball, go for a hike or a jog.
Write down on a piece of paper 3 things you want to do before January 1 of next year.
Click HERE for a downloadable pdf resource guide from the University of Michigan School of Medicine called Behavioral Activation for Depression.
Imagine a life filled with activities and productivity
If you are willing to make changes in your life to increase your behavioral activation, you are likely to become less depressed. Even if you do not have depression, behavioral activation strategies are good for your emotional well-being. You deserve this. Think about how it would feel to end the day and say, “I had a busy day. It was a little stressful and I’m tired, but I had fun and got a lot done.” An active day will help your sleep, your emotional health and your physical health. Taking care of yourself by planning and scheduling healthy activities is a proven strategy for starving out your depression and enhancing your mental and physical health.
For further reading, check out:
My Article, “Finding Quality Psychotherapy – Moving Beyond Talk Therapy”
My Article, “Cognitive Behavioral Therapy (CBT) – the Most Effective Therapy?”
Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back by Addis and Martell (See Len’s Book Review)
Activating Happiness: A Jump-Start Guide to Overcoming Low Motivation, Depression, or Just Feeling Stuck by Hershenberg (See Len’s Book Review)
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