Depression makes everything harder: motivation is low, we get little pleasure from things we normally enjoy, we have no energy, and relationships tend to be strained. Small wonder it’s the leading cause of disability in the world, according to the World Health Organization.
Several treatment options are effective in reducing depression. The majority of psychological treatments with strong research support are cognitive-behavioral (CBT) and focus on changing thoughts and behaviors to improve mood. Some forms of medication, such as the selective serotonin reuptake inhibitors (SSRIs), can be as effective as CBT, at least for as long as a person takes them.
So, which treatment option should a person choose? Obviously, it’s an individual choice and one that should be made in consultation with one’s doctor. For those who prefer to start with a psychological treatment—either because they’ve not found medications to be helpful and/or the side effects weren’t tolerable—CBT is a good candidate given the strong research support.
A recent study, the largest of its kind—showed that a simple treatment requiring less training than many CBT programs is highly effective in treating moderate to severe depression. Over 400 participants were randomly assigned to receive either a Cognitive Behavioral Therapy program (which focused on thoughts and beliefs, with secondary attention to behavior) or Behavioral Activation (the simpler treatment, focusing on behaviors that reduce depression).
The researchers introduced an important twist: Cognitive Behavioral Therapy was provided by an expert with extensive training, whereas Behavioral Activation treatment came from “junior mental health workers” without formal training in psychological treatments. Could the less experienced therapists with minimal training provide treatment that was as effective as the best-tested treatment delivered by experts?
The results are good news for making evidence-based treatments more widely available: Both treatment groups experienced, on average, about a 50% reduction in their symptoms, falling in the “mild depression” range at the end of 16 weeks of treatment. The study team also found that Behavioral Activation was significantly more cost-effective.
Thus, there is evidence that therapists with relatively little training can treat depression using a straightforward treatment.
But what if it’s hard to find someone in your area who provides Behavioral Activation, or if the treatment is prohibitively expensive and not covered by insurance (as if often the case)? For a person with mild-to-moderate depression, self-directed Behavioral Activation might be a good option. Multiple studies have found this approach to be effective, whether through a smartphone app or a book.
If you’re interested in doing this approach on your own, it’s important to understand what the treatment is based on and why it helps.
How Does Behavioral Activation Work?
We need activities in our lives that bring us enjoyment and a sense of competence and purpose. When we’re depressed we often stop doing a lot of things that bring us any reward. For example, we might choose to stay home rather than go out with friends because we don’t feel up to it, or we might watch our dirty dishes pile up as we struggle to motivate ourselves to clean. Or perhaps we’re only working and never playing, and draining our mental and emotional reserves. We might start to wonder what the point of life is if we’re never having fun.
Behavioral Activation includes the following basic steps:
- Identify what’s important to us in life’s major domains like relationships, work, spirituality, physical health, and so forth. For example, under work I might identify “being part of a collaborative team” as something of value to me.
- Once we’ve listed our values we look for activities that would fulfill each value—for example, “Volunteer for my company’s charitable giving committee.” The activities should be as specific as possible to make it easier to do them.
- After we have a list of activities that would support the kind of life we want, we plan specific ones to complete each week.
After doing these activities for a few weeks, a person generally starts to feel noticeably better.
How Can I Be More Active? I’m Depressed.
While Behavioral Activation is simple, it isn’t necessarily easy. A natural question about this approach is, “It’s hard to do anything—how am I supposed to do even more?” Motivation is almost always a major challenge with depression, and so we have to find ways to make it as easy as possible to do our activities.
In my book, Retrain Your Brain, Cognitive Behavioral Therapy in 7 Weeks, on self-directed CBT for anxiety and depression, one of the first chapters (“Getting Back to Life”) provides a step-by-step guide for Behavioral Activation. I include in the chapter several principles for how to approach the treatment:
- Start with easier activities. If your goal is to get back to running 3 miles, you might start by walking a mile with occasional spurts of jogging.
- Break each activity into manageable chunks. Maybe “clean the garage” is too daunting a task. You might start with a more specific task in the garage, like “Throw away old garden supplies from last year.”
- Plan activities that are enjoyable and/or important. It’s hard enough to motivate ourselves to do things we value, so make sure the activities you plan bring you some kind of reward.
- Plan a specific time for each activity. Picking a time to do an activity and putting that time in our calendar raises the odds that we’ll complete it.
- Build in accountability for your planned activities. When someone else knows our plan—or is even counting on us—we’re more likely to follow through. For example, knowing a workout partner will be waiting for us at the gym can provide extra incentive to exercise.
Over time a little change can lead to a lot of progress as the process builds on itself. As we do more rewarding activities and start feeling better, we have more energy and motivation to do what we want, which feeds back into more activity. By engaging in meaningful and enjoyable activities, we can build a life we’re excited to live.
By Seth J. Gillihan, Ph.D. Dr. Gillihan is a clinical assistant professor of psychology in the Psychiatry Department at the University of Pennsylvania.
This article first appeared in Psychology Today magazine.