Explainer: what is behavioural activation for depression?

A recent study from the United Kingdom found a simple form of therapy called behavioural activation (BA) is as effective in treating depression as more complex psychological treatments and even medication.

So, how does BA work and what is the relationship between behaviour and emotions?

What we do affects how we feel and vice versa

Emotions are important sources of information that guide our behaviour and enable us to function as human beings.

Happiness and contentment, for example, are the emotional rewards we receive for engaging in valued activities that improve our quality of life. Anxiety helps us to avoid dangerous situations that threaten our survival. Guilt motivates us to act respectfully towards each other and helps to maintain functional social relationships.

Sadness lets us know when we’ve lost something important to us. As a severe and prolonged form of sadness, the loss in depression is of self-worth and hope.

Just as our emotions guide our behaviour, the opposite is also true – our behaviour directly impacts our emotions.

The more we avoid risky or challenging situations, the less confidence we have in our ability to cope and the more anxious we feel. The more we treat others disrespectfully, the more guilt and regret we feel. And the more we withdraw from people and activities that have previously given us a sense of purpose and wonder in the world, the less happiness and more depressed we feel.

People with depression derive a diminished sense of pleasure and achievement from life. At its worst, depression is the absence of emotions. Without emotions we are lost – nothing has meaning, which makes it difficult to care about ourselves and others. Just as few of us would turn up to work without a financial reward, it can be difficult to turn up for life without an emotional reward.

The problem is that when depression leads to inactivity, withdrawal and isolation, there are even fewer opportunities to derive pleasure or a sense of achievement from life. As a consequence, depression, hopelessness, lethargy and motivation worsen over time. At this point, the “vicious cycle of depression” is in full swing.

Whether depression (the emotion) or withdrawal (the behaviour) occurs first is a case of the chicken or the egg. It does not matter. The critical point is that modifying our behaviour can have a powerful influence over our emotions.

What is behavioural activation?

The aim of BA is to reverse the cycle of depression by increasing engagement in valued activities, which increases our chances of deriving pleasure and a sense of achievement from life. BA has been used for decades as a stand-alone treatment for depression, or as the “behavioural” component of cognitive behaviour therapy (CBT).

The cognitive component of CBT teaches skills for challenging negative thoughts that worsen depressed mood. University of Exeter mental health researcher Professor David Richards‘ finding that BA was as effective at treating depression as CBT means it may be unnecessary to directly challenge negative thinking. Modifying behaviour may be enough to improve our outlook on life.

BA typically involves the following steps:

Step 1: Activity and mood monitoring

Depression usually makes it difficult to notice fluctuations in mood – everything seems black all the time. But moods do fluctuate, at least to some degree. The first step in BA is to become familiar with these fluctuations.

Write down the activities you do and rate your depression at the time (0 = no depression, 10 = extreme depression) every day for a week or two before moving on to step 2, but continue to monitor your activity and moods for up to 16 weeks.

Step 2: Notice the relationship between particular activities and your mood

When you look back over your activities and mood ratings each week, what activities were associated with a better mood (even slightly) and what activities were associated with a lower mood? Make a list of these activities under two headings – “better mood activities” and “lower mood activities”.

When you are depressed, you are likely to find more “lower mood” than “better mood” activities at the beginning. This is normal, but the idea is for this balance to shift over time.

Step 3: Schedule more of the “better mood” activities over the coming week

It sounds simple, but the next step is to schedule more of the “better mood” activities and steer clear of the “lower mood” activities. You might also schedule activities you previously enjoyed in your life, even if you don’t find them as rewarding at the moment.

Consider the days and times you are most likely to complete the activity over the coming week, schedule it in your diary, and problem-solve any obstacles that might get in the way. Plan some activities with loved ones for some additional support and encouragement.

Step 4: Balance pleasant and achievement-based activities

You might find that you do some activities just for pleasure (such as having coffee with a friend, dancing, or reading a book). Other activities might not be pleasurable, but they nonetheless give you a sense of achievement (such as cleaning the house, or going to work).

It is important to maintain a healthy balance of both pleasurable and achievement-based activities. Too many pleasurable activities can be unhelpful if it means we neglect our responsibilities, which then pile up and become overwhelming. On the other hand, too many achievement-based activities can feel like all work and no play. Some activities give us a sense of both pleasure and achievement – win, win!

Step 5: Action before (not after) motivation

This step is critical. If an activity is scheduled in the diary, then it gets done, regardless of how we are feeling. No exceptions.

A depressed mood will discourage us from making changes in our lives. The essence of BA is that if we behave as if we are depressed, then we will continue to feel depressed. Behaviour needs to change before emotions and motivation will improve, not the other way around.

If the activity in the diary is too challenging on a particular day, then do something that is less challenging but still moves you in a helpful direction. Starting slow is better than not starting at all.

To maintain motivation, keep in mind the long-term benefits of breaking the cycle of increasing withdrawal and worsening depression.

Step 6: Reward yourself

When you complete a scheduled activity, reward yourself. Think about natural rewards that might help motivate you to achieve your goals and reinforce your changes.

These rewards are likely to help lift your mood even further and may help you through the difficult times, because the road to recovery is likely to be rocky.

The advantages of behavioural activation

BA is no panacea, but it can be very effective at treating depression for many people.

BA is not rocket science, but simplicity is its major advantage over many other treatments. Simpler treatments can be taught more quickly and cheaply, and are more likely to be delivered with greater fidelity than more complex treatments.

Poor concentration is a common symptom of depression, so simplifying treatment may also help sufferers to apply the techniques long enough to experience the benefits.

Another advantage of BA is the absence of side effects, which is a common concern with medications.

Specialist and more expensive treatments can be reserved for people who really need them, which is important for minimising costs in health services with finite resources.

For more information on BA and self-help, visit the Centre for Clinical Interventions’ Back from the Bluez modules.

For information about depression and treatment options, visit beyondblue.

For free online or telephone assessment and treatment, visit Mindspot.

If you are in crisis, phone Lifeline on 13 11 14.

Peter McEvoy receives funding from the National Health and Medical Research Council. He is affiliated with the Centre for Clinical Interventions, Perth.