If you think of therapy for depression as all talk and no action, here’s a pleasant surprise—a simple, short-term and inexpensive new form of therapy helps people with depression feel better and improve their states of mind by “doing.”
Doing what? You’ll see…
TREATING DEPRESSION FROM THE OUTSIDE IN
Behavioral activation (BA), as the approach is called, helps people re-engage with others and with activities that they enjoy—or used to enjoy—rather than focusing on their inner thoughts and feelings.
“The treatment is straightforward but not simplistic,” explains Christopher Martell, PhD, clinic director of the Psychological Services Center at University of Massachusetts, Amherst, and the author of two textbooks on BA. “When people are depressed, they experience a reduction in reward in their lives, and they naturally withdraw socially and from activities they used to enjoy—and get pulled in by their negative moods. This sets up a bad cycle.”
That’s where BA comes in—breaking this negative cycle. It targets inertia, encouraging people to treat their depression through their behavior by “identifying barriers to participating in activities that used to give them pleasure or that might give them pleasure and helping them re-engage in those activities, little by little,” Dr. Martell explains.
MAKING YOUR OWN PLAN
Let’s say you enjoy, or used to enjoy, quilting. (In fact, it could be any activity you like, either alone or with others—cooking with friends, hiking, playing piano, being in a book club, drawing.) In therapy, you’d be encouraged to pursue that pastime in a small, incremental way—perhaps, say, by searching online for local quilting clubs to join. The next step might involve choosing a particular club and making inquiries about when it meets and whether it’s open to new members, then building upon the process from there. When internal barriers arise—if you can’t mobilize your efforts because you feel so down and tired, for example—you and the therapist would try to identify what’s really standing in your way and what you can do to get around those obstacles.
“The idea is that by engaging in meaningful activities, your mood will improve, your life will improve or both will improve,” explains Dr. Martell. “It’s not telling people to do certain things because we know they are good for them. This is a personalized approach, based on what someone wants or needs to have back in his/her life to improve the way he/she feels. When a person’s action gets a result, that makes engaging further more likely. It’s positive reinforcement.”
HOW WELL DOES BA WORK?
BA therapy has developed in its current form only within the past 20 years, so it is not as thoroughly researched as other forms of therapy. But studies with positive results are coming on strong…
• It works as well as cognitive behavioral therapy (CBT). One recent study, published in The Lancet, examined 440 adults who met a primary diagnosis of depression but who were not yet getting any treatment. About half got treatment by psychologists trained in CBT—a well-established approach that focuses on changing thought patterns and behaviors, which has been shown to treat depression effectively (and is even available in phone apps). The other half got treatment with junior mental health-care providers trained in BA. Each patient got at least eight weekly sessions of one of these types of therapy and then was re-evaluated a year later. Results: BA was just as effective as CBT and, because it could be provided by more junior professionals, less expensive.
• It works in younger people. A recent study from Japan, published in European Child & Adolescent Psychiatry, found that five weekly 60-minute sessions of BA helped college students with mild depression improve their depressive symptoms, quality of life and behavior.
• It works in older people. A recent study from the Weill Cornell Institute of Geriatric Psychiatry in White Plains, New York, published in American Journal of Geriatric Psychiatry, found that after 48 adults over age 60 (average age, 71) with mild-to-moderate depression were treated with nine weekly sessions of BA, they were engaged, participating in many more personally rewarding activities—and they experienced a sharp decline in their depressive symptoms.
THE EXERCISE CONNECTION
If BA could help people with depression become more physically active, the effects could be profound. Here’s why: According to a recent study published in Psychosomatic Medicine, 30 minutes of brisk exercise three times a week is not only as effective in treating depression as major antidepressants but much more effective in preventing the return of depression. Six months after treatment ended, only 8% in the exercise-only group had their depression return, compared with 38% in the drug-only group. (Here’s the best kind of exercise for depression.)
One recent study found that BA can help people who have both diabetes and depression—by getting them to enjoy exercise more. The diabetes/depression combination is surprisingly common, affecting close to half of Americans who have type 2 diabetes. In a 2016 study of 29 women, published in Behavioral Therapy, researchers at University of Massachusetts Medical School found that those who participated in a group exercise class that incorporated BA training, compared with those who got usual care, not only exercised more but had fewer depressive symptoms. While it’s a small study, if BA can get people to be more physically active, it could have a major impact on diabetes—and depression.
SHOULD YOU TRY BEHAVIORAL ACTIVATION?
“This is not the answer to depression—it’s one of many tools, along with CBT, interpersonal therapy and medications,” Dr. Martell says. “BA isn’t successful for everyone. But when it works, it can work very quickly. The exact mechanism of action isn’t clear, but re-engaging in activity can increase positive feelings—and the negative thinking that’s associated with depression can change as you change your behavior.”
While each patient and each therapist is individual, a typical course of BA consists of weekly 50-minute sessions for up to 24 weeks. It is a nondrug approach, but it can also work with individuals who are being treated with psychiatric medications such as antidepressants.
To find a BA therapist, the best place to start is with a therapist trained in CBT. “Most therapists trained in CBT can do BA,” says Dr. Martell. In fact, activation therapy has been a component of CBT for decades, often as a useful adjunct to other treatments—what’s new is the evidence that it’s effective as a stand-alone approach. “There is no special certification, although professional ethics requires that therapists have some level of training or study before implementing a specific treatment.” To find a CBT therapist, use the “find a therapist” link on the website of the Association for Behavioral and Cognitive Therapies. Like other psychotherapies, BA is generally covered by insurance. In addition, Dr. Martell is coauthor, along with Michael Addis, PhD, of a self-help workbook for the public, Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back. It helps readers focus on those activities that will inspire them with feelings of pleasure, mastery, and engagement, and it can be used on its own or in conjunction with a therapist. It’s widely available online.