My
study of the week to highlight is that of Professor Sona Dimidjian2
and colleagues at the University of Washington from 2006. They compared the efficacy of "doing", which
we are calling "behavioral activation", since we need a technical term to be
good academics, with cognitive therapy and antidepressant medication. They found that behavioral activation was
comparable to antidepressant medication for severely depressed patients, with both
being significantly better than cognitive therapy.
Putting
studies together can be confusing, but this combination of studies suggests
that doing is better than thinking about doing when you are severely depressed
and that doing outperforms the diminishing capacity for placebo response among
those who are severely depressed. We
expect these effects to be even more prominent for those who are mild to
moderately depressed.
What
is behavioral activation? In his classic
paper on depression from 1979, Aaron Beck emphasized the importance of "avoiding
and withdrawing" on the establishment and maintenance of depression. Behavioral activation attempts to engage and
interact. We look at what we are
avoiding and make plans for small steps to counteract that avoidance through
action in the world. One of our clients
was avoiding people and made herself go to ballroom dance class. This turned out to be enormously positive for
her mood. In Coyote Wisdom, I wrote about a client who turned around her
depression through stickfighting. This
activity gave her newfound confidence and sense of skill for engaging the world. One session with me and continuous training
in stickfighting turned out to be all she needed to resolve her depression.
Behavioral activation seeks to promote
activities that are consistent with our pre-depression long-term goals, while
finding and practicing more successful strategies for meeting those goals than
the ones we had previously used. We do
exercises in which we monitor our daily experiences, try experiments that
involve our behaving differently than we are inclined to do and monitor the results,
and use role-playing to learn and rehearse needed interpersonal interactional
skills.
As
an example, I proposed to one of my clients who believed he was hopeless and
nothing could ever change, to try an experiment in which, for one week, he did
the complete opposite of what he was inclined to do. I explained that this would be hard because
it would go against what he believed to be his nature. The first week went well. Yuri was tempted to let two friends crash on
his floor, but he knew them to be heavy alcohol and pot users and he was trying
to keep his consumption of both these substances on the lower side. He also knew that extracting them from the
floor could be difficult. He forced
himself to say, no. He justified his
decision by saying he had to go to bed early and get up early to get to
work. They would interfere with his
arriving to work on time and refreshed.
To his surprise, they agreed with him.
Their plan had been to party every evening and they were gracious about
his refusal. Next, he gave his
girlfriend a deadline for giving her a ride to an event on the weekend. If she wasn't going, he wanted to make other
plans. She missed the deadline and when
he made other plans, he resisted the temptation to drop everything and take her
at the last minute. She was not as
gracious about his decision, but that is to be expected in the nature of
interactions with ex-girlfriends.
I
proposed one more week of experiments.
This second week was not so successful.
He had found a place to rent of his own.
He had been living in the same house with his ex-girlfriend, which was
not conflict free. He announced to her
that he was moving into his own apartment, at which point she announced that
she would kill herself and he became paralyzed, falling back into the depths of
his depression, not knowing if he could move or not.
Here
is where some cognitive components crept into our discussions. Yuri's tendency was to minimize the distress
of others around him at his own detriment.
Stories existed to support how he had learned to do that, but this
tendency appeared to be associated with feeling helpless, and therefore, with
depression. The opposite behavior would
be to do what he wanted regardless of what others wanted. Of course, that could go too far, but there
was little risk of that in the inception.
I asked Yuri how many times his ex- had actually attempted suicide
compared to threatening it. He couldn't
remember any actual attempt. I
speculated that her strategy was probably more about manipulating him than
about ending her life and that he could continue the experiment and offer to
call emergency services for her if necessary.
This
sounded terribly calloused to him, but he agreed that his way wasn't working,
so why not try the experiment. He went
home, announced that he was moving anyway, and weathered the storms of
threatened suicide without capitulating.
Friends helped him move, and two weeks later, he was feeling much
better. His ex-girlfriend had only
gotten very drunk and had not tried to kill herself.
Doing
what he wanted to do instead of what she wanted him to do was associated with a
reduction in his symptoms of depression.
His moving out was more consistent with his long-term goals than staying
in a tense situation (because he got free rent for helping her around the
house). Long-term, he wanted a new
girlfriend, and even a long-term relationship.
Living with his ex-girlfriend was not terribly consistent with being
able to bring someone new home.
