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April 22, 2013

To Do and Not To Be

By Lewis Mehl-Madrona

I reflect upon the importance of doing, what is called behavioral activation. In order to change, we need to do things differently, and not just think about doing things differently. Unfortunately, conventional medicine has supported a narrative which tells us that we do not have to make an effort to change our behavior, so people who are depressed or anxious don't believe they need to do anything. We need to change this.

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Originally Published on FutureHealth

Doing instead of Being

Recently I read a blog on the importance of being instead of doing.  This essay was focused upon mindfulness and its use in people's daily lives.  To learn "to be" instead of "to do", however, implies that one has learned how to do.  For many of our clients, doing is still a challenge.

For this week's blog, I'm inspired to write about our clients who don't know how to do.  Change requires action.  In order to change, we have to do something differently.  It's not enough to reflect on change or to think about change.

Medicine and psychiatry have contributed to this passivity.  When we immerse people in the story that their problems stem from "bad brain chemistry", we take away any sense of agency they might have.  Within this narrative, our difficulties are not related to our lives or our relationships or our behaviors.  We have a disease like diabetes that must be treated with the right medications by an expert.  We aren't called to do anything to help ourselves.  In the daily practice of medicine and psychiatry, this is the attitude that I frequently encounter.  People come to me seeking the "right" medication that will make them feel "normal", though few can actually tell me what normal would feel like.  When I inquire more deeply, it's often the absence of emotion.  Clients even use the term "clinical depression" to refer to a depression that is endogenous, driven from within, outside the range of what they can influence.  "Clinical depression" requires a medication.

I usually try to understand what people mean by depression.  Does it mean excess sadness, indifference to life, hopelessness, despair, helplessness, or what?  These words mean so more to me than "depression".  People often struggle to define what they mean when they say depression.  The word is often a synonym for unhappy or miserable.

I find Jaak Panksepp's concept of depression helpful.  He speaks about a seeking system (which more conventional psychology calls the dopaminergic reward system).  All animals are hardwired to seek, Panksepp says.  What we seek varies by species.  Humans often seek what Marshall Rosenberg calls "needs", which include safety, love, connectedness, pleasure, and meaning and purpose.  We develop strategies for seeking, which may work more or less well.  When our seeking is frustrated, we feel angry.  When the outcome of our seeking is uncertain, we feel anxious.  When we come to believe that our seeking will never succeed, we get sad.  Stay sad long enough, and someone diagnoses you as depressed.  This fits well with Aaron Beck and the cognitive therapists' definition of depression as learned helplessness.  We've learned that nothing we do will get us what we want.  Often this is because our seeking is misguided or the strategies we have developed are ineffective.

Antidepressant medications are considered the standard of care currently for depression.  This is despite recent studies, which question their efficacy.  The most notable of these studies is that of Kirsch, et al., from 2008, from the University of Hull in the UK.  This team of researchers noted that published studies of antidepressant medications showed only modest benefits over placebo treatment and when unpublished trial data are included, the benefits fell below currently accepted levels for clinical significance, meaning that the benefits would have been too small to actually be noticed by patients or their doctors or by family members.  A large enough study can show statistical benefits that are so small as to be clinically useless. Kirsch and his colleagues obtained data on all the clinical trials submitted to the US Food and Drug Administration (FDA) for the licensing of four new antidepressants.  They found that drug--placebo differences increased as a function of initial severity, rising from virtually no difference at moderate levels of initial depression to a relatively small difference for patients with very severe depression, reaching conventional criteria for clinical significance only for patients at the upper end of the very severely depressed category. They determined that the relationship between initial severity and antidepressant efficacy was attributable to the decreased responsiveness to placebo among very severely depressed patients, rather than to an increased responsiveness to medication.

Curious, isn't it, that antidepressant medications are considered standard of care for depression when they don't actually do very much beyond placebo (which can be quite powerful, however).

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.

I have another client in which the activated behavior is to walk for one-half hour.  This client believes that everyone stares at him when he ventures outdoors and that people think he is a pervert.  He is also in one of my groups and I have noticed that he tends to stare at people for longer than most people like.  He also has some arthritis and some narrowing of the arteries in his legs.  This makes it more painful for him to walk than it would be for some others, but, paradoxically, walking is among the most helpful of therapies for arthritis and for narrowing of the arteries in the legs (peripheral vascular disease).  Previously, when he tried walking, he walked down Main St. in the direction of a crowded bakery, popular among many in town.  We settled on the smaller step of walking away from the center of town toward a relatively uncrowded park and away from the throngs of people.  We also practiced his staring at people's shoes instead of higher on their bodies.  This has been a more successful strategy and he is also learning how not to look threatening.

Catch me at Kripalu next week for Cherokee bodywork, April 28th to May 3rd.  Join our Wednesday, narrative lectures at noon, or come to narrative case conference on Thursdays at 1215, all on-line.  For details, see http://www.mehl-madrona.com and go to the tab for "My Online Meetings".  For information about Kripalu, go to http://www.kripalu.org, and search for "Mehl-Madrona Cherokee Bodywork", or email Email address removed

"Articles of the Week, mentioned above"

1. Kirsch, I., Deacon, B.J., Huedo-Medina, T.B., Scoboria, A.,  Moore, T., Johnson, B.T., (2008). Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. PLoS Medicine, 5(2), 260-268.

2. Dimidjian, S., Dobson, K.S., Kohlenberg, R.J., Gallop, R., Markley, D.K., Atkins, D.C., Hollon, S.D., Schmaling, K.B., Addis, M.E., McGlinchey, J.B., Gollan, J.K., 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, DOI: 10.1037/0022-006X.74.4.658.



Submitters Bio:
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 Vermont. He is currently teaching in the Clinical Psychology Program at Union Institute and University in Brattleboro, Vermont, and has a part-time private practice there. He is the author of several books about integrating narrative and indigenous ideas with modern medicine and psychiatry including Coyote Medicine, Coyote Healing, Coyote Wisdom, Narrative Medicine, and Healing the Mind through the Power of Story.

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