Depression makes everything harder, including the stuff we used to enjoy. This can lead us to avoid those things. Unfortunately, when depression and avoidance join forces, it can be really bad news.
Behavioral activation is a treatment for depression that helps people focus on re-engagement with their lives. Specifically, it gets people doing precisely the things that are likely to improve their mood (Jacobson, Martell, & Dimidjian, 2001). Generally, when a depressed person is in behavioral activation treatment, they change the activities in their life to lessen depression. The therapist helps them to structure their lives differently.
Rather than assuming that there is a deficiency in the depressed individual, behavioral activation takes a more practical approach. It examines what is occurring in the person’s life to worsen or maintain the depression. This often involves looking at the things they do, the situations they find themselves in, and the things they avoid.
The role of avoidance
Often, avoidance is one of the key components of depression. People struggling with depression often withdraw or isolate themselves. To the depressed person, withdrawing and isolating may seem as good ways to avoid unpleasant interactions, like getting into an argument with a parent or being criticized by a spouse.
However, this avoidance has a side effect of preventing them from having any positive interactions. For example, let’s say (hypothetical client) Sal tells me he “lays in bed all day because dealing with people is too exhausting.” He likely will continue to feel lethargic and unmotivated to engage in work (or play). This may lead to his having issues at work (e.g. tardiness, unexplained absences). Will these issues help his depression? No, they will only worsen it.
Sal also denies himself the chance to have positive interactions with coworkers that might improve his mood. His repertoire of activities becomes limited as well; e.g., prior to feeling depressed he may have made social plans after work, but now he just wants to go home and sleep.
Sal’s changes in daily routines would be another major focus in behavioral activation treatment. Such changes might include more time spent sleeping, going to bed earlier, spending less time with friends. When our healthy daily and weekly routines get disrupted, mood can worsen. This happens because we are out of sync with the larger environment. For example, Sal is now sleeping at 8pm when his friends are getting together to see a show or have dinner. These changes affect the way Sal interacts with his environment, and in this case, they worsen his depressive symptoms.
How does therapy address depression and avoidance?
Using a behavioral activation approach, I would encourage Sal to examine how his behaviors are maintaining or exacerbating his depression. Once we have a clear understanding of how his behaviors might maintain and/or worsen his depression, Sal’s work is to “do something different.” Rather than continue to engage in ill-serving behaviors (isolating) and behavior patterns (waking late and being tardy to work), Sal would work toward small, day-to-day, changes that will promote more pleasurable experiences.
Additionally, behavioral activation recommends that behavior is best directed by priorities and goals agreed upon in therapy — not how the person is feeling in a given moment. In Sal’s case, I would advise him to set a routine sleep and wake time. It would be important for him to stick to this goal, regardless of how he feels. If Sal set a goal to go to bed at 10pm, but has gotten into the habit of going to bed at 8pm, we would brainstorm ways he might fill those hours with activities that ideally would be enjoyable. Regardless, Sal would be cautioned against going to bed at 8pm, even if he was having a particularly bad day. If he goes to bed early, he will miss out on the opportunity to have a mood-lifting experience.
The bottom line
Depression and avoidance can supercharge one another. How can Sal get out of the vicious cycle they create? The behavioral treatment of depression will help him focus on tangible changes to make in his daily life. These changes will likely to lead to improved mood. What can Sal do differently today and this week that will potentially lead to a different outcome than his previous days and weeks? Unless Sal sets a “do something different” goal, nothing will change.
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