Behavioral Activation to Treat Depression

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It is estimated that in 2016, over 16 million adults in the U.S. had a major depressive episode. This represents almost 7% of all adults in the United States. Even more shocking, this number only accounts for a small subset of individuals with depression, as not everyone with clinical depression meets the diagnostic criteria for a major depressive episode. Sadly, most people suffering with depression do not seek treatment despite the development of very effective treatment methods in the last few years. Recent research has demonstrated that cognitive behavioral therapy is the gold standard in treating depression.

Cognitive-behavioral models of depression have long held that depression is the result of an interaction between thoughts, feelings, and behavior (e.g., Beck et al., 1979; Rehm, 1977). Simply put, situations trigger some response of one of these elements, for example, thoughts. The thoughts then cause a chain reaction in which feelings are influenced, which in turn trigger behaviors, often resulting in a kind of emotional snowball with a momentum of its own. An example of this is someone not being invited to go out after work with the rest of one’s coworkers. This may trigger the thought “No one likes me.” As a result of this thought, sadness is elicited, causing the person to go straight home and lie in bed. Having only one’s negative thoughts to occupy one’s mind, this cycle becomes stronger and stronger.

The cognitive behavioral approach to therapy is to target the thoughts, the behavior, or both to break the momentum of this system and inspire new emotions, thoughts, and behaviors to arise. Significant evidence suggests that merely increasing rewarding behaviors is a very effective way to effectively treat depression. Behavioral Activation (Martell et al., 2010) is a CBT treatment that has shown significant success in research studies. In fact, Behavioral Activation has been shown to be just as effective as antidepressant medication at reducing depressive symptoms, and even more effective than medication at keeping the symptoms from recurring after treatment (Dobson et al., 2008).

The premise of behavioral activation treatment is that once we get in a depressive cycle, we slowly withdraw from activities that are rewarding. People who are depressed often spend too much time in bed, watching TV, avoiding people and beneficial activities. Behavioral activation is about gradually re-introducing rewarding activities back into people’s routines. These activities can either be pleasurable, such as going for a walk or scheduling dinner with a friend, or mastery-oriented, such as painting the bedroom or volunteering at a charity. After a period of consistently engaging in reinforcing activities, mood gradually improves, resulting in less self-defeating thoughts, and the upward mood cycle builds momentum.

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The primary way of going about behavioral activation is through activity monitoring and activity scheduling. Keeping a detailed record of behavior during the week as well as tracking feelings of pleasure and mastery associated with each behavior, serve as a guide to what might be missing from your routine. After tracking this for a few days to a week, the following weeks are spent gradually increasing rewarding behavior into your day by scheduling the new rewarding behaviors. In this way, people can come out of their depressive cycles by replacing them with contentment cycles. Sounds simple, but in practice it can be quite difficult to engage in any activity when you’re feeling unmotivated.  Consequently, behavioral activation is usually most effective with the help of a trained cognitive-behavioral therapist, who knows techniques to aid behavior modification and knows how to avoid potential pitfalls that can derail progress early on. Studies have shown behavioral activation for depression with a CBT therapist can improve symptoms after just the first session, with most people showing significant symptom reduction/remission after as few as 12 sessions.

If you or someone you know is struggling with depression, behavioral activation may be the right treatment for you. For more information on cognitive behavioral therapy and cognitive behavioral treatment of depression, visit Cognitive Behavioral Therapy Los Angeles.

 

Beck, A.T. et al. (1979). Cognitive Therapy of Depression. New York: Guilford.

Dobson, K.S. et al. (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76, 3, 468-477.

Rehm, L.P. (1977). A self-control model of depression. Behavior Therapy, 8, 787-804.

Martell, C.R., Dimidjian, S, & Herman-Dunn, R. (2010). Behavioral Activation for Depression. New York: Guilford. 

CBT Techniques: Treating Thoughts as Guesses

Many people try cognitive behavioral therapy to learn how to better manage their emotions. Others seek help in curbing a destructive behavioral pattern, such as an addiction. In each case, one of the most powerful ways to help people change their emotions or behaviors is to start by helping them learn to change their thoughts. One of the many CBT techniques designed to aid in this task is treating thoughts as guesses.

We all have thoughts about the world we live in, our relationships, ourselves, the future, the past… Thoughts are an incredibly powerful tool human beings have to understand the world around them. It is our ability to create mental representations of things and concepts in our minds that allows us to solve problems, create, and hopefully improve our lives. Unfortunately, however, thoughts also have the potential to cause suffering, creating rather than solving problems.

People suffering from emotional problems, such as depression or anxiety, have learned to think in ways that perpetuate the problematic emotion. For example, people with depression tend to make sense of the world in more pessimistic ways, often involving thoughts that they are helpless to improve things. Similarly, people with anxiety disorders frequently overestimate the likelihood of danger in their lives. These patterns of thinking serve to reinforce and intensify problems with emotion dysregulation, which in turn validate negative thought patterns, and function similar to a self-fulfilling prophecy.

 One CBT technique to reverse this negative feedback loop is to relate to thoughts less as facts and more as guesses. The reality is, many of the thoughts we have are not facts. They are merely conclusions that we develop in response to a limited set of facts. For instance, if you decide to enroll in a foreign language class and have difficulty after the first day, based on the limited number of facts available, you may have thoughts that it is too difficult, and that you are just not cut out for learning languages. These thoughts may cause you to feel very discouraged, drop the class, and avoid future language learning opportunities.

The thought “I can’t learn new languages,” is not itself a fact, but a conclusion drawn after your first class. It is very possible that with continued effort and practice in the class, what you thought was difficult on the first day may seem easy just a few weeks later. However, if you relate to “I can’t learn new languages” as an incontrovertible truth, chances are you will never stick with the language long enough to realize this. In this way, confusing thoughts with facts can be detrimental to your self-esteem and sense of agency.

The key is to begin to think of thoughts as guesses, or hypotheses. Using the same scenario above, if after the first day you are overwhelmed, having thoughts of “I’m not smart enough to learn languages,” and begin to feel discouraged, you might do well to consider alternative explanations:

·       It may be that because this is new, it’s very unfamiliar and initially seems more difficult than it really is.
·       This is just the first class. It will likely become easier with time and repetition.
·       New subjects are usually more difficult at the beginning, so maybe I should give it more time and assess my ability level later on.
·       It might actually be very difficult, but that doesn’t mean I can’t learn it. I may just have to work harder than I assumed initially.
·      Even if I do face a lot of difficulty or don’t learn the language perfectly, it is worth it to me to give it a try. After all, there were reasons why I wanted to learn this language, and none of them are because I thought it would be very easy.
 

Challenging yourself to treat your initial assumption as one of many possible guesses can be helpful in not rigidly holding onto it, and instead being able to shift flexibly to other, more helpful conclusions. By considering a range of possibilities it becomes easier to go with the one that seems the most effective, in this case, the one that helps you stick with the language class long enough to achieve your language goal.

There are many cognitive behavioral therapy techniques designed to help you learn to see thoughts as guesses. In fact, in some ways most CBT techniques are designed to do just that. You can try the following technique to help you consider a range of possibilities the next time you feel stuck:

1. When you are feeling an especially strong negative emotion, such as anger, sadness, or anxiety, stop and identify the thoughts that seem most responsible for fueling the emotion.

2. Pick the thought that packs the most punch, and remember that it is just one way of making sense of the available facts, and is not necessarily a fact itself.

3. Brainstorm as many other hypotheses as you can, regardless of whether or not you believe them.

4. Pick a few that seem helpful, and write out how you might feel or act differently if you adopted this new thought

5. Once you decide on the most helpful way of making sense of the current situation, reminder yourself of this new thought as much as you can. It won’t make the other thought disappear, but it will certainly reduce the old thought’s airtime in your mind, making it less dominant over your feelings and behavior.
 

By switching your orientation to thoughts as guesses instead of facts, you can learn to more flexibly and effectively think about a variety of different situations. Ultimately, this will likely result in you feeling better when challenges arise. Loosening your grip on unhelpful thought patterns can also help you make better choices, and act more effectively in difficult circumstances.