and the rest of us. Try to pick a popular song that captures the essence of a given type of therapy. Freudian psychotherapy focuses on the effect of your parents on mental health, just like when Loggins and Messina sing, “Your momma don’t dance and your daddy don’t rock and roll.” General supportive therapy creates a safe environment where you can talk about your feelings, even if this approach does not lead to concrete action or immediate change, just like Karen Carpenter in “Rainy Days and Mondays.” Drug and alcohol counseling uses a technique where the patient, not the therapist, elaborates the reasons why he or she wants to quit using substances, just like Ringo Starr announcing, “No, no, no no, I don’t smoke it no more.”
For behavioral activation, the song which best describes this form of psychotherapy is “Get Up and Boogie” from 1975 by the Silver Convention. If you don’t know it, I’ll save you the time of Googling the lyrics. The whole song is just, well, “Get up and boogie…..Get up and boogie….Get up and boogie….boogie….That’s right.”
In 11 years of primary care, I’ve seen a lot of depressed people, and I have found behavioral activation to be the single most powerful tool available to help depression quickly. A few randomized trials have compared this treatment, behavioral activation, to medications and other types of psychotherapy. It always comes out as equal to or better than other approaches.
What is behavioral activation? Why is it so effective? What are its limitations? Why is this method not more popular among therapists?
To understand what behavioral activation is, we first need to find out what it is not. Behavioral activation is not about your early childhood experiences, listening to you talk extensively about your feelings, or trying to unbrainwash you out of irrational, negative thoughts. Of course, clinicians trying to help depressed patients with this technique definitely want to hear you tell your story and they want to understand your history in some detail, but the actual therapy does not focus on these things. It focuses on behavior. Neurobiologists believe depression is caused by abnormal brain chemistry, Freudians think it is caused by early childhood experiences, and cognitive therapists think it is caused by what you are thinking, but clinicians using behavioral activation say depression is caused by what you are doing.
Behavioral activation believes that depression is caused by sitting on the couch, watching reruns of Oprah, and eating Ben & Jerry’s. It is caused by lying in bed all morning and not getting up to do something. It is caused by avoiding a problem instead of solving it. In short, behavioral activation is the most simpleminded, brain-dead, one-dimensional, nonintellectual approach to helping a depressed person out there, except perhaps for Bobby McFerrin’s 1988 song, “Don’t Worry, Be Happy,” and dagnabbit, it is beguilingly effective. Can you imagine some clinical psychologist looking at this approach and saying, “I slugged it out at Yale getting my PhD for this?”
In Anna Karenina, Tolstoy tells us, “All happy families are alike, but an unhappy family is unhappy after its own fashion.” Behavioral activation sees it as just the opposite. All unhappy people are unhappy for the same reason—they are behaviorally deactivated. Happy people are all different.
Treating depressed patients with this methodology is not as simple as I’m making it out to be. The challenge is not in mastering a large, complex, theoretical framework. We know the patient just needs to get up and boogie, but how do you get someone who feels like s*%t to do that? Changing their behavior is the difficult part.
When helping depressed patients with this technique, I begin by presenting the model of behavioral activation. I was fortunate to be able to attend a seminar by Chris Martell, PhD, who is one of the founders of this methodology and has written a couple of books on it.
Dr. Martell attended the “Eschew Obfuscation” institute for his English degree, so his books are not that helpful, but in person and watching the training videos, the method does come to life. Behavioral activation is a whiteboard-and-marker approach. Tweed jackets and pipes are not part of the treatment.
Elegantly stated, the central tenant of this approach is that people feel like crap because their lives suck. It makes sense that someone whose life is bad feels bad. Depression often starts with a life event. That event could be anything—the loss of a job, bad weather in Seattle, whatever. But the net result is that the patient now has a less rewarding life. Imagine you work for $50,000 annually for the phone company. Suddenly, no one wants regular phone lines anymore and your boss cuts your pay to $30,000. Your life is less rewarding. For the amount of effort put in, you are getting fewer rewards. The correct strategy in this situation might be to look for a new job or get some extra training and improve your skills. But someone who is prone to depression does not see this pay cut as a call to action; he sees it as a psychic injury and he responds by withdrawing. That withdrawal makes him less likely to be engaged in work, less likely to look for a new job, less likely to want to pursue additional training. The result is an even less rewarding life, and this creates a positive feedback loop. According to behavioral activation, most depressed people are spinning in this loop of unhappiness and that is why they are depressed. Depressed people are withdrawn, deactivated, not doing things for fun, not taking on interesting challenges, and it is this behavioral state which causes persistent depression.
Sometimes, patients are highly activated, but in ways that don’t provide adequate rewards. Imagine someone who works for a graphic design firm. He has been there for 20 years and is tired of having a boss. He wants to run his own company, not work for someone else. That individual might be very busy, but not in a way that is bringing rewards. Or consider a stay-at-home mom who is bored and restless and wants to work. She is likely busy all day long, but again, not activated in a way that is bringing her rewards. Getting patients activated in ways they find rewarding is the goal of this form of treatment. Behavioral activation has several tools that can be used to help patients. One is to have folks carry around a calendar for the week and write down everything they are doing and what their mood is at that time. One of my patients discovered that she was watching TV five hours per day and her mood was always down during and after TV, but it was much higher when she worked on job applications or went downtown shopping and met up with friends. Another patient discovered that going shopping with his wife made his mood poor, but working on a business deal (he was retired) made him happy.
Another method is to use the calendar to schedule activities and provide structure in the patient’s life. We know that one of the reasons why severely depressed people improve during a mental health hospitalization is that the environment is highly structured, and there are specific activities and treatments that require participation throughout the day.
A skilled clinician doing behavioral activation is always mindful that patients put up roadblocks. There is often “some reason” why the patient can’t do a particular activity. Sometimes, it is helpful to break up a task into simple steps and get the patient to start on the first one. This approach was parodied in the very entertaining movie, What about Bob? with Bill Murray and Richard Dreyfuss. Often, getting a patient to take that first small step is enough to start the activating process. In one video of this technique, Dr. Martell is seen using his PhD in clinical psychology to help a patient fill out the first page of a health insurance form. They filled out the first page in the office so that the patient would complete the rest at home.
Proponents of behavioral activation will point out that this technique is at its best with very depressed patients, folks who are just sitting at home all day on the sofa doing nothing. Getting these people do to something that is fun and rewarding or productive and satisfying can help improve mood almost instantaneously. However, I have found the technique equally helpful with patients who are less depressed but leading unhappy lives.
Many therapists are willing to incorporate some activating strategies
into treatment, but are uncomfortable just focusing
on what patients are doing without investigating and treating
the supposed root causes of the problem.
There are many fine points that go into being effective with this technique and I’m just giving a broad overview here, but behavioral activation is a great approach for primary care physicians. Primary care doctors are the main providers of mental health care in the United States, and unfortunately because of how medical care is paid for by insurance companies and the government, almost no primary care doctor is allowed the time to provide this very effective methodology to patients. As a result, most primary care mental health focuses on prescribing medications to the exclusion of psychotherapy, even when good approaches like this one are available.
Why is behavioral activation less popular among practicing therapists when it is such a powerful technique? I think part of the reason is that therapists like deep explanations for patients’ problems, not superficial ones. Many therapists are willing to incorporate some activating strategies into treatment, but are uncomfortable just focusing on what patients are doing without investigating and treating the supposed root causes of the problem. Whether a deeper examination is truly necessary is a very open question and from the available research, we can conclude that it is not necessary in many cases.
I feel that behavioral activation, all by itself, is a powerful tool and a great approach for psychologists, psychiatrists, social workers, school counselors, primary care physicians, life coaches, and others who encounter and treat depressed individuals. Sometimes we can get so bogged down in the details of early childhood experiences, irrational thoughts, interpersonal relationships, and brain biochemistry that we neglect the most obvious way to help depressed patients—having them get up and boogie. That’s right.