Behavioral Activation: A Simple and Proven Treatment for Depression

What is Behavioral Activation?

When it comes to treating depression, most mental health professionals talk about either medications or therapies such as cognitive therapy. These are, no doubt, clinically relevant treatments for depression. However, with the recent emphasis on treating the "chemical imbalance," simple treatments for depression such as behavioral activation have been sidelined. Behavioral activation is an evidenced-based treatment for depression and complements other treatments of depression (American Psychiatric Association, 2010). In fact, research demonstrates that in individuals with severe depression, behavioral activation is comparable to antidepressant medication and better than Cognitive Behavioral Therapy (Dimidjian et al., 2006). Avoidance is a key target for change in behavioral activation. The lack of energy and motivation in depression can result in people with depression either cutting back on pleasurable activities or not enjoying them as they used to. Avoidance brings a temporary relief to an individual as then they are not under pressure to do a task. This then reinforces more avoidance, but when things don't get done, one becomes more frustrated which then feeds into depression, thus creating a vicious cycle. One aspect of behavioral activation geared toward addressing avoidance is activity scheduling, which involves strategies to increase the amount of time an individual with depression spends in activities that enhance their sense of pleasure or accomplishment. This is achieved by keeping an activity log as described next.

Keeping a Daily Activity Log

A good way to track if you are engaging in pleasurable activities is to keep a daily activity log, an example of which is in table 1.

Table 1: Daily Activity Log.

Time of the day	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Early morning
Mid-morning
Noon
Afternoon
Evening
Night

 

Use the daily activity log to record all the things you have done while you are awake. Put each activity into one of the five categories listed below (Duggal, 2016). An activity may be put in more than one category simultaneously. These categories are subjective and you define what they mean to you.

Neutral activities (N): These are activities which you do as a part of your daily routine and they are neither pleasurable nor disliked. These are usually activities of daily living. Examples include, doing household chores, brushing your teeth, taking a shower, eating, driving to work, etc.

Unpleasant activities (U): This category includes activities which you are obligated to do, but dislike them or try to avoid them. They also include any situation that makes you physically or emotionally uncomfortable. For example, paying bills, paying taxes, unpleasant social situations, unnecessary meetings at work, taking care of sick relatives, etc.

Pleasurable activities (P): This category is self-explanatory. Common examples include, exercising, hobbies, listening to music (not sad music), going to a movie, going for a holiday, spending time with family and friends, playing sports, going for a walk, playing musical instruments, going out to dinner, watching TV, buying things, meditating, making love, reading books or magazines, etc.

Activities with a sense of mastery or accomplishment (M): These are activities that make you feel useful and productive and give you a sense of purpose. They are usually goal driven and require an effort to complete. For example, working on a project, learning new skills at your job, improving your performance in sports or other hobbies, planning or organizing activities, improving your efficiency at any skill, etc.

Activities which put you in a state of flow (F): A person in a state of flow pays undivided attention to the task at hand to the exclusion of other things happening in their own bodies or external environment. There is a feeling of spontaneity, with loss of sense of time, and the task appears to “flow” on by itself. Athletes, painters, and other creative people have described this state as an ecstatic feeling or a feeling of content. This feeling of flow is, however, not limited to sports or creative arts. These activities represent the pinnacle of satisfaction and are mostly moments of time when you are engrossed in either a pleasurable activity or an activity that gives you a sense of mastery. 

You can use letters N (Neutral), U (Unpleasant), P (Pleasurable), M (Mastery), and F (Flow) for the five categories. Categorize all the activities you have recorded on the daily activity log using this key. If you find completing a daily activity log for an entire week too taxing, you can complete one on alternate days in a week. An example of a daily activity log completed for a single day is in table 2. Make sure to include at least one weekend day to get a more complete picture of your week.

Table 2:  Example of a Daily Activity Log for a Single Day.               

Time of the day	Monday activities (categorize as N/U/P/M/F)
Early Morning	Woke up (N), took shower and got ready for work (N), ate breakfast (N), drove to work (N), listened to music while driving (P).
Mid-Morning	Worked on ongoing project (P, M), got some coffee along with a coworker (P), had a meeting with the team (U).
Noon	Ate lunch (N), went for a short walk (P), called my spouse (P).
Afternoon	Helped a client (M), got called to an urgent meeting (U), worked more on report (P, M), collaborated with a coworker on a project (M), replied to an email from boss (U).
Evening	Drove back home (N), ate dinner (N), spent time with spouse and kids (P).
Night	Watched TV (N, P), called parents (N), read a book to kids (P), worked more on an article (P, M, F), watched some more TV (N).

Mapping your daily activities provides you a snapshot of how your moods vary depending on the activity you do. This exercise gives you motivation to make changes in your day-to-day life if you get the sense that you may be depriving yourself of activities which give you a sense of pleasure or mastery. 

Analyzing Your Daily Activity Log and Making Changes

Once you have completed the daily activity log for a few days, the next step is to analyze it and use it to make modifications to your day. Ask yourself the following questions (Duggal, 2016):

• “Am I doing too little of the Pleasurable/Mastery/Flow (P/M/F) activities, thus, depriving myself from feeling happy?”
• “Is there a right balance of activities between Neutral/Unpleasant (N/U) activities and P/M/F activities?”
• “Am I relying mostly on M activities to make myself feel better without doing much of P activities?”
• “Can I reduce the frequency of U activities?”
• “If I cannot avoid the N activities, can I intersperse them with P/M/F activities?”
• “Are there certain times of the day (e.g., evenings) or certain days of the week (e.g., weekends), when I feel really low and my log for those times is devoid of P/M/F activities?”
• “What P/M/F activities are more helpful in improving my mood than others?”
• “Am I avoiding doing some of the P/M/F activities? If so, why?

Tips on Creating an Effective Behavioral Activation Plan

• Start slow and start with simple things on your list of “P/M/F” activities. If you haven’t been physically active in a while, you will feel more rewarded by going on a short walk rather than a two mile run.
• It is easier to do a task for a set period of time rather than trying to complete a certain portion of the task. Try to read a book for five minutes rather than reading a whole chapter.
• Break a big task down into smaller steps and reward yourself for competing those steps.
• Choose high-yield P/M/F activities that are beneficial over a long term basis. Exercise, hobbies, meditation, sports, and positive social interactions are some of them.
• Enjoy the process of doing the activities and don’t focus on outcomes alone. Continuous evaluation of a new activity will mostly likely lead to the preemptive conclusion, "This isn't working, because I still feel depressed."  
• If you choose reading a book or watching a movie as your pleasurable activity, make sure that these are not stories about human tragedies, which may have a contrary effect on your mood.
• Pleasurable activities are everyday enjoyable things and don’t have to be expensive or exotic.
• Stay committed to your plan and don’t succumb to diversionary activities, which get you off-track. When you feel overwhelmed or frustrated, your mind will automatically find something else to do. Resist this temptation.
• Try an activity at least three times before concluding that it had no impact on your mood. 
• Learn to savor the joyful moments through all your senses when you doing something pleasurable. 
• If you are having difficulty in starting your plan, explore for any underlying irrational thoughts or core beliefs that may be contributing to this. These are thoughts like “Nothing works,” or “I can’t do this.” 
• One of the most common reasons that people with depression cite for avoidance is lack of motivation. However, if one keeps waiting for motivation to kick in before doing a task, then they are putting the cart before the horse. Action precedes motivation and not the other way around.

To summarize, behavioral activation is a useful tool to add to your repertoire of coping skills to self-manage depression, even if your are on medications or in therapy. To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.

HARPREET S. DUGGAL, MD, FAPA

REFERENCES

American Psychiatric Association (2010). Practice guidelines for the treatment of patients with major depressive disorder (3rd ed.). Arlington, VA: American Psychiatric Association.

Dimidjian, S., Hollon, S. D., Dobson, K. S., Schmaling, K. B., Kohlenberg, R. J., Addis, M. E., Gallop, R., McGlinchey, J. B., Markley, D. K., Gollan, J. K., Atkins, D. C., Dunner, D. L., & Jacobson, N. S. (2006). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. Journal of Consulting and Clinical Psychology, 74(4), 658-670.

Duggal, H.S. (2016). The Complete Guide to Self-Management of Depression. Bloomington, IN: Archway Publishing.