The risk then is that people withdraw further. They choose easy but unrewarding behaviours instead, such as staying at home (even as lockdown is lifted or as new social opportunities arise). At first, this makes good sense. ‘This withdrawal is driven by people’s desire to avoid the negative emotions that they’re experiencing when they try to do these activities,’ according to David Richards, a professor of mental health services research at the University of Exeter. McMillan agrees, adding that this behaviour ‘works in the immediate term because it makes you feel better’. The difficulty lies in what this inactivity sets up in the long term. The risk, he says, is that ‘it moves you further from what you need to do to get something out of the world’.
The key to relieving depression, according to behavioural approaches, is to somehow break this cycle of inactivity and low mood. This is the main goal of the behavioural treatment that the American psychologist Peter Lewinsohn and his colleagues began developing in the 1960s. Today, this approach is known as behavioural activation (BA) and is well-established as an effective psychological therapy for depression.
In BA, people experiencing depression are gradually encouraged to engage in the very activities they have stopped doing. The idea is that the cycle of inactivity and low mood is replaced with a more beneficial cycle in which productive, meaningful activities make people feel better, which in turn increases motivation for more activity. One participant from a research study about BA described the process: ‘I think [BA] helped me a lot because then I started to take care of some stuff and got it done. Just the happy feeling that you get when you have managed to accomplish your goal.’
BA is a standalone treatment, but its principles often appear in other forms of therapy, including cognitive behavioural therapy (CBT). In fact, in one study comparing different types of therapy, BA was just as effective at reducing depression as full CBT. Although BA was originally developed as a therapist-led treatment, it involves simple principles that you can implement yourself to improve your mood.NEED TO KNOWWHAT
TO DOKEY POINTSLEARN MORELINKS & BOOKS
What to do
Monitor what you do each day. The first step involves keeping a record of all your activities for about a week. There are free worksheets available online, but you can make one yourself. Draw up an empty timetable, splitting each day into hourly slots or into morning, afternoon and evening. Then, for a week, make a note of what you did each day. Critically, you should also make a note of how you felt during each activity, from 0 (feeling really down) to 10 (feeling positive and upbeat). For example, you might note that you watched TV in the morning and your mood was about a 3, then you did a yoga class in the afternoon and your mood was about a 5. ‘The idea is that this step helps gather information about the small changes in behaviour that could make a big difference but that we often overlook,’ says Laura Pass, a clinical psychologist at the University of East Anglia.
If the idea of tracking your activities for a full week seems daunting, then you could do it for less time. ‘The aim is to set the recording-activities step at a level that is manageable for the person,’ says Pass. ‘So this might be doing one day, or doing a few time-points during the week.’ She stresses that this step can be tailored to the individual: ‘For example, for a young person, a parent might help them complete this.’
If the idea of tracking your behaviour at all seems too hard, BA principles could still be useful to you – just skip this step and go to the ‘Make a plan’ step below. ‘Personally, I don’t think it’s absolutely essential to do the baseline activity,’ Richards says. Pass agrees, emphasising that the key is about changing future behaviour. ‘So if someone is able to do that without recording their activity, that’s still positive.’
Evaluate what you did. If you tracked your activities and mood, then reflect on what you were doing when your mood was higher. It doesn’t matter if your mood was never very high; that’s common, particularly if you’ve had a prolonged period of feeling down or depressed. A small increase in mood is still helpful and will inform the next step.
Make a plan for the following week. Now you need to schedule activities for the upcoming week, using the same blank worksheet as before. Look back at your diary from the previous week, and include in your schedule the activities you were doing when you experienced a slightly better mood. In addition, try to include some of the activities you have stopped doing, or are doing less often now. You don’t need to fill out every slot, but aim to schedule at least one or two activities for each day.
To figure out the kind of things you should include, it’s useful to think about not just what you enjoy but also what you find meaningful or important – or what you used to, before this period of low mood or lockdown. ‘The idea is to personally identify what’s important to you in your life,’ says Pass. ‘It’s about where you want your life to be going.’ If you enjoy going out with friends, for example, you could invite someone to go for a coffee, or make plans to call a friend. If you value learning, you could plan to take a book out of the library or listen to a new podcast. There isn’t a set list of activities you’re supposed to try; schedules for a school-age teenager, a working parent and a pensioner might vary considerably. What matters to you will depend on your own unique circumstances.
There might be some less fun things in your schedule, too. If it’s important for you to have a tidy house or flat, for example, you might want to schedule some cleaning or a clearout. McMillan emphasises that it’s about finding a balance between three different types of activity: the pleasurable (such as seeing a friend), the routine (showering, cooking) and the necessary – where the consequences of not doing an activity are significant (academic work, paying bills). ‘It isn’t just about doing nice things,’ he says. ‘It’s just as important to get up and brush your teeth and have a bath. It’s about doing things that get you something positive in life.’
In your new schedule, avoid prolonged periods of not doing very much. In particular, be on the lookout for anything from the previous week that helped you to avoid or escape more fulfilling activity. For example, you might have stayed in bed late so you would miss a certain meeting at work, or spent hours scrolling through social media instead of going out with friends or chatting to them on Zoom. Even though these low-effort behaviours might feel appealing in the moment, they could be maintaining your low mood. This is because, when you do these activities, they’re filling up time that you could otherwise spend doing something positive. Doing very little at home or choosing to relax aren’t problematic behaviours in and of themselves; they become problematic only if you’re using them to avoid doing something more important. Try to spot any behaviours that you use to withdraw from the world, and avoid scheduling these for the following week.
Stick to the plan, even when you don’t feel like it. A key aspect of BA is that you need to carry out all your planned activities even when you don’t feel like it. According to the theory, opportunities for positive mood-change occur only once you’re doing the activity, so it’s important to attempt it in spite of how you’re feeling. ‘It’s useful to think about working “from the outside in, not the inside out”,’ says McMillan. ‘Rather than telling yourself: “When I feel better, I’ll do the activity then,” you’re changing your behaviour first, then the thoughts and the feelings catch up.’
If it feels impossible to get going, there are a number of things you can try. First, you could break down the activity into smaller steps or do it for shorter periods of time. Richards gives an example: ‘If someone is avoiding cleaning their home because it’s overwhelming, then it makes sense to clean just one part of your home.’ Second, it might be useful to order your list of planned activities in terms of how difficult they seem, and attempt the smaller, easier ones first. For example, instead of planning to join a gym and trying out an exercise class, a first step might be walking around the block, or trying an exercise video on YouTube, before attending the gym at a quiet, off-peak time.
Finally, you could experiment with strategies that boost the chances of completing your activities. McMillan emphasises the importance of setting up the right context. He suggests that you ask yourself: ‘What’s going to make the behaviour more likely to happen?’ Consider, for example, writing down the task somewhere you’ll see it, or asking a friend to do the activity with you.
Evaluate how it went. At the end of each day, reflect on how you felt when you did each activity. Note which activities led to an increase in positive mood, even if it was small, and which contributed to a lower mood. Notice any other benefits you experienced: maybe you felt a sense of achievement for giving something a go, or a sense of relief for tackling a job you’d been putting off for ages. This will help when planning activities in future weeks. Also note the times when you felt unable to start or complete an activity in your schedule, and think about how you might make it more manageable the next time.
Be patient with yourself. Remember that an improvement in mood might not be instant. ‘[The behaviour] might just be really difficult to do now you’re feeling low, now the context has changed,’ says McMillan. ‘It might feel hard for a while, but if you can, keep going with it. One useful idea is to see it as an experiment: try to experiment with the behaviour long enough to find out what it does for you. It could well take a few weeks to find that out.’
Key points
- According to behavioural theories, doing fewer enjoyable activities contributes to maintaining depression. Behavioural activation therapy works by breaking the cycle between inactivity and low mood.
- If you experienced low mood or depression during lockdown, you might find it particularly daunting to plan activities again, but finding ways to re-engage with life could be key to improving your feelings.
- Keep a diary of how you spend your time, for a few days or a week if possible. Break down your activities by the hour, or by morning, afternoon and evening – whatever is easiest and makes most sense for you. For each activity, record how you felt, from 0 (lowest mood) to 10 (happiest mood).
- Make a plan of activities for the following week. Include activities that led to a happier mood the previous week, and ones that you think are important or meaningful – especially those that you have recently stopped doing, if possible. Avoid passive activities, such as lying on the sofa all day, or any activities that corresponded with a low mood in the previous week.
- Try to complete activities even when you don’t feel like it. The idea is that the behaviour comes first, then the improved mood will gradually follow.
- At the end of the week, evaluate how you felt doing different activities, and use this to plan the next week.
- Repeat the above steps, and be patient. The early days are about giving things a go, and taking small steps towards activities that you need to do or that matter to you. It’s about getting your life back on track, even if you don’t feel better straight away. Remember that it can take some time before you see an improvement in your mood.
Learn more
At the heart of BA lies a simple psychological principle: operant conditioning, named by the American psychologist B F Skinner in his paper ‘Two Types of Conditioned Reflex’ (1937). According to this principle, there are two reasons why we might carry out a behaviour. First, because it leads to something good, such as enjoyment or progress (this is known as ‘positive reinforcement’). Second, because it means that we avoid or escape something bad, such as pain or embarrassment (‘negative reinforcement’). So we might keep going back to the coffee shop because we like the buzzy, alert feeling we get from an espresso, or we might take painkillers because they get rid of a nasty headache.
Behavioural theory states that depression can be explained, in part, by a dearth of positive reinforcement. This lack of positive reinforcement is often a result of the significant context shift: things that once led to good outcomes (such as pleasure or meaning) have suddenly become harder to access, seem less appealing or have disappeared altogether.
Negative reinforcement also plays a role. When a person feels that going out and doing things has become difficult and stressful, it’s understandable that they might want to retreat and avoid those activities. When this withdrawal becomes a means of escaping from potentially negative feelings, the behaviour is reinforced, meaning that the person wants to keep doing it. ‘If people are finding it difficult to deal with the world at large, staying at home is negatively reinforcing,’ says Richards.
Negative reinforcement and a lack of positive reinforcement feed off each other. The more time a person spends doing behaviours such as staying in bed, the less time there is to do purposeful activity that could lead to some benefits. The fundamental aim of BA is to tackle this imbalance between positive and negative reinforcement. ‘If you reduce avoidance behaviour, you give people more opportunity to experience more positive reinforcement,’ says Richards.
A key challenge that often arises in BA is that the beneficial activity is simply not possible. In some cases, the activity used to be available but isn’t anymore, often because of the big context shift. McMillan uses the example of a person who is no longer able to play golf because of a long-term illness. In such cases, a process known as functional equivalence can be explored. This involves reflecting on the behaviour that’s no longer possible in order to work out what the benefits were, and then finding an alternative behaviour that might give the same results.
In the case of the golfer, this would mean reflecting on whether another activity might offer some of the same benefits that golf did. ‘Often, there are six or seven functions [of an activity],’ says McMillan. ‘What was it about playing golf that you liked? It might be that it got you out in fresh air, it got you away from a difficult situation at home. So how can we get those things, given you now can’t play golf?’ McMillan emphasises that there might not be a neat mapping between the original behaviour and the new one; there might be three or four new behaviours required to meet the function of the old behaviour. Richards agrees: ‘The function of the behaviour is the key thing. What was in it for you when you did that behaviour?’ The goal is to find new ways to achieve the old positive results.
You can try this for yourself. Start by writing out some key things that you used to enjoy and that you now do less often (either because of your mood or by force of circumstance). For each one, write down what it was about the behaviour that you enjoyed. Was it getting exercise, talking to people, feeling intellectually stimulated? Remember that there might be several benefits for each behaviour. Then, for each benefit, list out some potential activities that you can still do and that might get you a similar result – new activities that have a functional equivalence with the old activities.
For young people, particularly those younger than 18, there might be various reasons why an activity is not possible. ‘Teenagers don’t have much autonomy or free time,’ says Pass, who researches BA in adolescents. ‘There are lots of constraints for them. It might be lack of money or needing parental approval.’ In these cases, it can be important to have parental involvement in scheduling helpful activities. ‘That’s where we find having parents or family can be really helpful to removing those barriers,’ she says. ‘Parents can be a great facilitator.’
No psychological therapy works for everyone, and this is true for BA. In one study, 70 per cent of participants who received BA no longer met the criteria for depression 12 months later. There are a number of reasons why it might not be effective for an individual. For example, people of all ages might need someone to help them plan and carry out their activities, and this assistance isn’t always available. ‘Social support is helpful,’ says Pass. ‘If [the person with depression] hasn’t got a team around them, that can be hard – if they haven’t got someone willing to help support them through the process.’
For clinical depression, research indicates that treatment is generally more effective if guided by a therapist. Richards suggests that, in BA, this is partly because working out the functional equivalence of past behaviours can be tricky to do on your own. ‘In BA, it might be that working out the key function of past behaviour is hard,’ he says. ‘People might not know why they do something. This is why a therapist is helpful.’ If the steps above prove too difficult to do on your own, you could try speaking to a mental health professional.
Behavioural models are not the only tool for understanding depression, and BA is not the only solution. However, the potential benefit of BA lies in its simplicity and its firm roots in fundamental psychological theory. If you recognise yourself in this article – if you find that you’re feeling low, and that you’re doing fewer of the things you once enjoyed (even as opportunities are opening up again post-lockdown) – then these principles could be useful to you. The important thing is to think about how you’re spending your time, and how different activities make you feel. Gradually introduce activities that will bring you pleasure and a sense of achievement, even if they don’t lead to immediate improvement. Being active and making plans when you feel down is challenging but, over time, it can be key to lifting your mood.
Links & books
Carol Vivyan, a mental health nurse based in Guernsey, offers a free, printable blank activity diary on her website.
The Norwich Medical School at the University of East Anglia provides detailed guidance about the steps of BA.
David Richards recommends the workbook Overcoming Depression One Step at a Time: The New Behavioral Activation Approach to Getting Your Life Back (2004) by the American psychologists Michael Addis and Christopher Martell.
Laura Pass recommends a pair of books on adolescent depression by the British psychologists Shirley Reynolds and Monika Parkinson. Both include behavioural-activation principles. The first, Teenage Depression: A CBT Guide for Parents (2015), is aimed at parents; the second, Am I Depressed and What Can I Do About It?: A CBT Guide for Teenagers Experiencing Low Mood and Depression (2015), is aimed at young people themselves.