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Articles    H3'ed 4/22/13

To Do and Not To Be

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Message Lewis Mehl-Madrona


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.


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Lewis grew up in southeastern Kentucky and attended Indiana University where he majored in biophysics. He then attended Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of (more...)
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