What to Do If You Are Depressed: Behavioral Activation

A blog series guiding folks who are depressed.

Posted Jun 20, 2019

Welcome to Part IX in our “What to Do If You Are Depressed” blog series. We are now in the second half of the series and have moved from Awareness and Acceptance to principles of Active change that foster adaptive living. The last installment (VIII) oriented us towards reflecting on and clarifying our values. That allowed us to understand what it is we are trying to move toward, in both the short and long term. Today our focus is on behavioral activation (BA), which is a central psychological principle in dealing with depression. (If you are new to the series and would like to start from the beginning, go here).

BA is about deliberately working toward ways you can reverse cycles of avoidance and become more positively engaged in the world around you. This likely sounds pretty obvious (which in some ways it is), but we should note it is not necessarily easy to do. In Blog VIII, we mentioned a way to frame the pattern of shutdown via the acronym “T R A P”, which is an acronym for Trigger, Response, and Avoidance Pattern. We want to avoid TRAPs and engage in positive activation.

Let me translate what this means: A stressor (either outside your head like someone criticizing you, or inside your head, like a scary thought or image) hits your consciousness. That “trigger” results in a painful “response” and that gets you to act via an “avoidance pattern” to be safe. An example can help illustrate what I mean: Joan wakes up and starts imagining her day and thinks about going to work and then being criticized by her boss about something she did. This image becomes a "Trigger" and the emotional "Response" in Joan’s head is a jolt of fear, pain, and resentment. That makes her want to hide and stay in bed, which is the "Avoidance Pattern". It is a classic depressive TRAP. To see why let’s play it out. If Joan responds this way, what will the consequence be? If she calls in sick and then lies in bed, where is she but sitting in the cave of depression? Not only that, she still has to wonder if her boss is going to critique her and now she has missed more time from work, so she is further behind. And it would be likely that she now feels ineffective and has nothing productive to do. That is the nightmare of depressive cycles. They spiral you into the cave. Via avoidance, Joan tried to escape the pain. But her instinct to avoid actually caused her to jump out of the pan and right into the fire.

What should Joan have done? Ideally, she would have mindfully “held” her feelings, then she would have worked to think things through constructively, and then she would have guided herself to act in a way that was consistent with BA.

In future blogs, we will explore how to think adaptively and mindfully hold one’s feelings. Today our focus is on diving into BA. At its core, BA is about deliberately working to construct one’s way of being in the world that increases engagement, pleasure, and productivity. Over time, this produces what is called a “virtuous growth cycle,” as opposed to the destructive cycle of a shutdown. More specifically, BA is about finding pathways of positive investment that: (a) move a person toward specific goals and thus more valued ways of being; (b) result in mastery, competence or achievement and the experience of growing and learning; and/or (c) are pleasurable or entertaining. For a depressed individual, this may well sound both simple and unhelpful. I can hear folks responding with the thought: “If my life was like that, then I would not be depressed!” We can acknowledge this initial negative reaction. In holding it, it does not follow that we need to give into the avoidance pattern that follows from it (i.e., the conclusion being that there is nothing that can be done). Instead, the philosophy of BA is an attitude that fosters working toward positive investment. 

How does one actually do this? There are many guides for how to accomplish this. Here is a good presentation on the basics of Behavioral Activation. I recommend you spend some time with it (or something similar--feel free to Google "behavioral activation" and look around). As is noted in the guide, BA includes a number of elements, such as 1) Understanding the “vicious cycles” of depression; 2) Identifying goals and values; 3) Monitoring daily activities; 4) Building an upward spiral of motivation and energy through pleasure and mastery; 5) Activity Scheduling; 6) Problem solving around potential barriers to activation; 7) Working to reverse TRAPs; and 8) Maintaining an attitude that fosters learning and growth. The guide also includes a detailed description of things like goals, values, mastery and pleasure, ways to engage in activity scheduling, and ways to identify your core values and goals. It also provides lists of the kinds of activities that many people who are depressed find pleasurable. And it suggests ways to “experiment,” and see which ones are the best for you.

Let me add a few things to the model of BA that they offer. First, let me note what I call the problem of initiation. One of the things depressed moods do is they “kill” behavioral initiation. This means that, for many depressed folks, it is really hard to get started on new activities. If you are one of these people, I encourage you to employ what I call the five-minute rule. This is when you make an agreement with yourself that you do the activity for five minutes. Once folks get started and past the initial “inertia” of the shutdown, then they find that the activity takes on a better emotional tone. For example, I am not a huge fan of exercising. And, often, on my ride home from work, a little voice inside my head invites me to keep on driving past the gym, often with some excuse, like it has been a stressful day. My reply to myself is often something like, "Yes, I do feel like crap today for good reason. So, I will go to the gym and start my work out. If, after five minutes, I still feel like crap, then I will give myself permission to head out." Usually, five minutes into my workout, I am in a different place and it is much easier to finish it up and by the time I am done, I am glad I did it and feel a sense of accomplishment. 

The second idea I would offer is what I call the pay it forward principle. This refers to the fact that your future self will benefit if you are able to manage to engage in constructive action. Recall the example of Joan. Because she did not deal with the problem, her “future self” now had more problems to deal with. This means hard things built up. If she had gotten out of bed, and faced the situation effectively--even if she felt miserable during that day--she likely would have woken up the next morning feeling as though she accomplished something. If you have a productive day even if you are not feeling it when it is happening, your future self will likely feel it--just as if you have an unproductive day, your future self will feel that in the opposite way.

I also recommend that in your work on fostering greater BA, try to be clear as to why you are doing what you are doing in terms of your values. For example, if you are cleaning your room, focus on the goal and the fact that doing it moves you to a valued outcome, rather than the thought that you hate dusting or doing laundry. It might help if you think of this as a kind of “behavioral engineering”. You are working to act in your daily life so that it is more engaging, rewarding and leads to greater levels of mastery, goal accomplishment and pleasure.

In the next blog, we continue with this theme of BA, only there we will focus more on how to construct healthy daily habits and lifestyles. One way to bridge from this blog to the next one is to focus on activity scheduling. Activity scheduling refers to the way you plan out what you are doing. I recommend a weekly planner that gives a basic structure to the week. I also recommend a daily planner. The daily planner is something you do either in the morning when you get up or the night before. It lists the basic tasks and activities for the day. So, today, when I got up, I generated my task list, which included finishing and posting this blog, doing laundry, mowing the lawn, and taking my car to get its oil changed.

It is hard for me to overstate how important BA is to reversing depressive cycles. A good case can be made that BA has more scientific support for treating depressive conditions than any other principle. Of course, if we consider depression as a state of behavioral shutdown, the logic makes good sense. We must also note here that to be successful in employing BA, you will need to learn it and practice it and grow from it. As with all the principles that follow, this takes time and effort. And it involves learning at the levels of a) thinking and understanding (i.e., knowing what shutdown and activation are at deeper levels); b) feeling (feeling both the shutdown and the hope and commitment to try to reverse it and feeling the consequences of both), and c) doing (genuinely trying new things and learning from them and adjusting and working to find what is rewarding for you).

This all takes time. This blog gives an outline, but I recommend you seriously "sit" with these ideas and consider really committing to them. To do so you need to immerse yourself in them. There are several excellent books that guide you through this "BA engineering" process. Two such books are:

Overcoming Depression One Step at a Time

Control Your Depression

We have now covered two core principles of Active change. In the previous blog, we covered values clarification and here that of BA. In the next blog, we expand the BA principle from a general way of responding to a way of cultivating a particular kind of lifestyle. I look forward to continuing on this journey with you.