Co-written by Anh Dao and Darby Saxbe.
Are you currently feeling trapped in the black hole of depression? Getting out of bed is a monumental task, but annoyingly, your therapist seems to keep asking you to “do more.” Behavioral activation, or the notion of “doing more to feel better,” can feel invalidating, and being reminded of the things you avoid doing is even more aggravating – how could doing yoga, or even worse, working through countless activity worksheets, possibly put any dent in the sticky darkness of your depressive episode?
Returning to hobbies or spending time with friends sounds nice, but it is the last thing on your mind when daily tasks and responsibilities feel unsurmountable. And yet, current research on behavioral activation, which addresses symptoms of depression through intentional engagement in rewarding and fulfilling activities, has consistently shown that behavioral activation is a powerful tool against depression (Dimidjian et al., 2011; Imai et al., 2020; Wang & Feng, 2022). Importantly, while researchers do not fully understand what the “secret sauce” is behind the effectiveness of behavioral activation (Cohen et al., 2023; Forbes, 2020), they agree that it is beyond just “doing more.”
Behavioral activation is a highly effective, brief, and structured intervention for depression (Wang & Feng, 2022). The primary goal of behavioral activation treatments is to “activate” one’s contact with rewarding experiences in their daily lives and systematically target problems hindering such activation (i.e., symptoms of depression or avoidance strategies; Dimidjian et al., 2011). Moving past the simple idea of increasing activity to improve mood, behavioral activation encourages creative problem-solving and gaining new rewarding experiences through activating behaviors.
Crucially, behavioral activation also involves identifying links between actions and emotions to understand the consequences of avoidance and can ultimately assist in developing greater self-efficacy and resilience against the recurrence of depressive symptoms in the future. Researchers at the University of Cambridge have posited that the effectiveness of behavioral activation also relies on changing the way you think and perceive your role in building a rewarding life (Myles & Merlo, 2022), and, thus, should always be coupled with careful reflection.
Behavioral activation commonly includes a diverse repertoire of skills and techniques that work in tandem with each other. To better illustrate this, think of the machinery found on bicycles. The extent to which you understand behavioral activation techniques and the frequency of skill application in your daily life are pivotal gear cogs initiating forward momentum. On the other hand, behavioral activation is the chain that links such movement to treatment outcomes. The chain of behavioral activation triggers a cascade of adaptive changes into motion, while avoidance or inhibition may result in chain misalignment and gears getting “stuck,” increasing a person’s risk of traveling on a downward spiral of depression.
Related to this, researchers at the University of California, Los Angeles, have suggested that behavioral activation is likely effective due to the ways distinct parts of such a therapeutic machinery operate together (Cohen et al., 2023). In other words, cogs (i.e., engaging and planning rewarding activities) can’t move the gear of well-being without being connected to the chain (i.e., the ability to appreciate and anticipate future rewarding events or changes in the perception of your role in creating a rewarding life), and the chain can’t function properly if not supported and guided by the cogs. Lastly, the cogs and chain need to fit well with each other to ensure fluid movement, which highlights the importance of trying out different cogs, gaining an understanding of the structure of your chain, and ultimately, personalizing your machinery of behavioral activation.
You may be wondering, what are the links in a chain or cogs in the gears of behavioral activation, and how do you choose the one that works best for you? We do not fully know (yet), but reward processing may be an essential piece of the machinery (Forbes, 2020; Nagy et al., 2020). Behavioral activation can be traced to Dr. Peter Lewisohn’s theory of behavioral causes of depression (Lewinsohn, 1974), which suggested that depressive symptoms resulted from decreased contact with rewarding experiences and a person’s responses to rewards. Importantly, neuroscience research has corroborated this notion. Specifically, in a review of prior published studies, researchers found that people with depression commonly had impairments in neural reward processing (Halahakoon et al., 2020). Several studies have also found that individuals with decreases in neural reward responses to rewards show the greatest improvements following treatment (Burkhouse et al., 2016; Dickey et al., 2023).
Taken together, these studies show that behavioral changes seem to be associated with adaptive cognitive change in the brain (Norbury et al., 2024), and they highlight one’s active role in the process of understanding and modifying activation and avoidance behaviors. Researchers at leading academic institutions have begun to test novel neuroscience-informed interventions for depression that enhance anticipation, appreciation, and learning from rewards with promising results (Burkhouse et al., 2023; Craske et al., 2016, 2019). Developing interventions that are built to reinforce specific chains or mechanisms of change is a promising direction in enhancing the machinery of behavioral activation.
If you feel like drowning due to depression, setting up your behavioral activation “gear cogs” can be a powerful first step to re-establish your life through small victories. However, don’t forget that the gear only forms a small (but crucial) part of the machinery. Strengthening the “chains” or active mechanisms of behavioral activation is crucial in helping you consider ways you can build your set of attainable behavioral and cognitive changes that will help you move forward at your own pace.
Anh Dao is a graduate student in the USC Clinical Psychology Ph.D. program.
References
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