“When the going gets tough, the tough get going.”
– From the song by Billy Ocean
“Behavioural activation? You mean getting me to do stuff?”
The trainee therapist stumbled over her words. “Well I suppose that’s another way of putting it!”
Getting people to do stuff – okay, ‘behavioural activation’ (BA) – has a lot going for it and is the basis of behavioural therapy.
In one study, BA was found to be as effective a treatment for mild to moderate depression over a six-month period as cognitive behavioural therapy (CBT).1 And it has the advantage over CBT of being cheaper and not requiring a highly trained person to deliver it.
I do wonder whether the young therapist was trying to prove something when she named the technique rather than simply implementing it! One sign of professional insecurity is to try too hard to look professional, and to overcomplicate things as a result. The trainee therapist was great, but she was somewhat jargon heavy and that was the way she’d been trained.
I asked myself, what drives the increasing complication of therapy? Insecurity? Commerce? Professional pride? Intolerance of uncertainty? Fear of revealing that therapy is really a commonplace, everyday endeavour (that happens to be able to change lives)?
Some (though certainly not all) clients may be impressed by complicated terms, perhaps feeling that it sounds more ‘proper’. But clarity is to be valued too! Anyway, I digress…
Call it what you want, inspiring action in depressed clients as part of forming a road map out of depression is a vital part of treatment. And it can be useful for all sorts of other conditions as well.
Completing the loop between thoughts and reality
Imagination and conjecture are poor replacements for reality.
Samantha was terrified she had upset her friend. I’d seen this client a few times for problems with assertiveness and moderate depression. In this session she told me she hadn’t been sleeping because she felt a simple comment she’d made to this pal may have ruined the friendship.
“I have a phone right here!” I said.
She looked at me wide eyed. “You mean…?”
“Of course. Why not? Right now all we have is your imaginings, but you need to know, right?”
So accustomed was Samantha to not acting, but simply mulling, it hadn’t occurred to her to actually ask her friend whether she had upset her.
She called, and I left the room to let them speak. At least we would know, and then have something real to deal with.
When I returned, Samantha beamed at me.
“Well? Did you ruin your relationship with one well-intentioned remark?” I already knew the answer.
“No! My friend laughed. She didn’t even notice what I’d said and couldn’t recall it. She has been really busy, but we’re meeting up tonight. I feel so relieved Mark!”
The psychological paralysis of depression
We are born to act. Yet those who develop depression often feel paralyzed to engage with life. Forming and pursuing goals can feel like an impossible step. If you ask a depressed person what they want, they may only be able to talk about what they don’t want.
Depression sucks energy and self-belief. Learned helplessness, the feeling and belief that “nothing I do can make any difference”, becomes the mind’s default setting. Life grinds to a halt and starts to feel meaningless. Activities that used to be enjoyable come to feel pointless or impossible.
Yet, like bump starting a car down a hill, sometimes movement itself will get the engine going even though the vehicle seemed all but dead to begin with.
Often the very thing the depressed client needs to do may be the very last thing they feel able to do.
Of course, we all have to think things over sometimes – to problem solve, or be creative, or simply reflect. But depression has us living in our heads in a seemingly inescapable circular maze of mirrors.
When treating anyone for depression, we always need to address rumination.
Chewing the cud without processing it
Rumination is what cows do when they chew over cud, then swallow it, then regurgitate it, then chew it again… and so on. Eventually they will process it. We, on the other hand, can psychologically chew stuff, and regurgitate it repeatedly, but not digest or process it. People can mull over the same old stuff for years on end and still be no better off than when they started.
When we negatively ruminate, we go over material in the mind repeatedly without actively problem solving or reframing the problem being obsessed over. When we don’t act to solve our problems, we may simply ‘stew’ or ‘mull’. Imagination can imitate reality, as it did for Samantha, but it is a poor replacement for problem solving.
If the problem seems insoluble at the moment, then we ‘solve’ it by feeling and thinking differently about it. If, ultimately, it is solvable, we can help our clients find constructive ways to deal with it so they can better meet their primal emotional needs. Samantha no longer had to chew her problem over, because she processed it by discovering that her worry was manufactured and didn’t accord with reality.
Rumination has been found to cause and fuel depression.2,3 But why should rumination without action make us depressed?
Excessive rumination leads to excessive dreaming
Depressed people over-dream, and it’s more than just a symptom. Even artificially limiting REM by waking people up to interrupt it can lift depression fast.4
We often seem to dream about unresolved emotional arousals. This seems to be one of the roles of dreaming – to attempt to clear those emotional arousals or expectations.5 In fact, many antidepressants, when they do help people beyond a placebo effect, may do so by suppressing REM (not by raising serotonin levels as was once believed).6
The trouble is, if we just suppress REM – and therefore the release of emotional energy – the depressed person may continue to have strong emotions but no longer have a means of discharging them. This may be one reason that some antidepressants raise the risk of suicide attempts or even homicide.7 Not the kind of behavioural activation we want!
If we ruminate too much (because we are not solving problems or reframing), we become exhausted and feel helpless and hopeless.
It’s better, of course, to lower excessive sleep-time REM by naturally reducing daytime rumination. And one way to do that is through effective behavioural activation strategies.
The antidepressant effects of limiting rumination
Positive activity can help us:
- solve problems so we don’t have to ruminate about them
- increase our confidence to actually be more proactive, and
- decrease rumination as attention is focused away from the self.
As a result of all this, energy can be mobilized. Helping depressed people is partly about helping them ruminate less, and partly about changing the way they ruminate so that when they do, they do it with hope and flexibility. Ruminating excessively with hope has been found not to be depressing.8 It’s not just how much you dwell on stuff but how you dwell on stuff.
So to help our depressed clients, not only do we need to help them think differently (and sometimes help free them from PTSD) but, critically, we also need to help them act in the world to better meet their primal emotional needs.
I’ve written before about how best to set tasks for clients so they are more likely to actually carry them out. Here I’ll give you three more considerations when using behavioural activation for depressed clients.
Tip one: Discuss past enjoyments in depth
Memories mobilize not just the mind but the body too. Recalling bad memories can even be dangerous, as when strongly recalling times of anger reduces the pumping efficiency of the heart.9Memories mobilize not just the mind but the body tooClick To Tweet
But as writer and doctor Herbert Benson discovered, recalling times when we felt healthy and happy can likewise affect us physically, increasing our immunity and sense of wellbeing.10 Adolescents at risk of developing depression seem to be protected, and become more emotionally resilient, when they are encouraged to recall happy events.11
One way to activate memory is through conversation. So simply asking about former enjoyable activities, whether it be dancing, singing, sport, or fun with friends, can help the client access those times emotionally – and benefit from them physically.
Artfully and gently helping someone evoke and revivify past good times (in such a way as to avoid making them simply lament that those good times are not here now!) can have surprisingly powerful effects on mood.
I use hypnosis to maximize the reassociation to past good times with my clients. I also use hypnosis to help the client pre-experience carrying out healthy behaviours, making it more likely they will actually activate those behaviours in future.
Being reminded of, in a sense reliving, a great and rewarding activity is a great way to feel motivated to chase some more.
Mind you, it has to be the right activity.
Tip two: Form goals based around the client’s values
For our behaviour to feel meaningful, it needs to accord with what we feel is worthwhile. So often when we want to help others we impose our own ideas as to what they ‘should’ do (“You should start clay pigeon shooting!”). But of course, it needs to be their thing. We need to help clients form goals around their interests and values.
So, for example, if your client feels helping others is important, they might form a goal of volunteering for a charity once a week. You could then help reinforce that goal by reminding them of the research showing that volunteering confers great health and wellbeing benefits.12
Likewise, if career, physical fitness, or learning new skills is important to your client, then goals centred around these value sets will be most compelling for them.
But we need to avoid overwhelming our clients.
Tip three: Start with the smallest of steps
Behavioural activation will only happen if the client feels able to act. We can help them break goals down into manageable steps.
I’ve noticed, paradoxically, that if we make really small behavioural requests of our clients they will often ‘rebel’ and do much more than we ask. For example, I asked one depressed client who usually loved dancing to show up at her local dance class just for half an hour. Later she reported that she had stayed for the full lesson and actually joined in!
But we do have to make small requests. If someone says they want to “get organized”, we need to ask what specifically needs to be organized. We can then ask what the smallest initial step towards getting organized is. It might be to tackle their tax return, or tidy their home.
I will then ask them whether it’s reasonable for them to spend five minutes filing tax returns or cleaning. Most people can agree to do such a small amount.
I will ask them to set a timer for five minutes and no more. But often the client will report that they ‘cheated’ and completed the whole task. The human impulse to complete a pattern once it has been instigated is universal.
This is why cliffhangers work in fiction. A storyline pattern has been instigated, and now we crave its completion. Completing a task that has a beginning, middle, and end is uniquely satisfying and antidepressive.
The need to complete patterns (even tax filing ones!) once started is strong.
Tip four: Make goals measurable
If there is resistance to goals, it may be because they feel impossible and overwhelming, which is why we need to be mindful of tip three. Or it might be because it’s not clear what needs to happen. That’s why it’s so important to define the tasks that the client must complete in order to work towards their goals.
We can help our clients create tasks around their values, and list them from easiest to hardest. And we can ask them solution-focused questions like “How will you know when you have done that?”
If the client has an actual way of ticking off completed tasks (maybe on a spreadsheet or simply a notepad) it will help bring order to their desired future behaviour. There are few things more satisfying in life than ticking off a task once completed. Even if that task is to just do five minutes of cleaning!
If someone is really down on themselves, we may need to reframe the idea of engaging in pleasurable behaviours as self-maintenance, or “the happier you are the more you can help others.”
Behavioural activation – getting people to do stuff – can be fun and creative, and the effects can be magical. And it can help clients to find pleasure and meaning in unexpected places.
Some people like to subdivide behavioural activation into (a) engaging in intrinsically satisfying behaviours, what we might call healthy pleasures, and (b) engaging in behaviours that have been put off but that need attention (tax return, anyone?). But in fact, and rather strangely, we often draw great pleasure from this latter category as well.
We don’t just take pleasure from the more obviously pleasurable activities in life. Finally completing tasks we had been avoiding for a long time can be surprisingly and powerfully pleasurable! A combined sense of relief and achievement is one of life’s underrated pleasures and can also help us feel confident and empowered.
In the words of Henry Ford, who wasn’t a man averse to behavioural activation: “Think you can or think you can’t. Either way you’re right.”
We can help people think they can, then help them do right by themselves.
For more on treating depression, our online course How to Lift Depression Fast provides a structured approach, helping you understand depression and providing a simple framework for leading clients out of it. Read more about the course here and sign up to be notified when it is open for booking.
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