Behavioural Activation for depression
Like many, 50-year-old Jane Curnow credits overcoming depression to an absorbing hobby. Curnow was diagnosed with clinical depression at the age of 32 and had made two attempts on her life.
“I had spent my entire adult life in and out of therapy,” she says, explaining that her depression stemmed from life circumstances and low self-worth.
Curnow had always enjoyed fitness and at 46 took up body-building, which grew into a passion. “My hobby not only cured my depression but saved my life. After four years of body-building I declared myself fully recovered and celebrated my 50th birthday on stage to declare my recovery to the world.”
Describing her cure as accidental, Curnow is now a Sydney-based health and lifestyle coach and fitness model and has written a book about her experiences, Finding Myself from the Outside In.
Like Curnow, many sufferers of depression stumble accidentally on the therapeutic advantages of activities. But what if health practitioners began prescribing them as a conscious treatment for depression? It’s a tantalising proposition gaining traction in Britain. Thanks to a 2016 Lancet study, the therapy (dubbed “behavioural activation” or BA for short), is officially being promoted as a legitimate treatment for depression by Britain’s National Institute for Health and Care Excellence (NICE).
In the biggest trial of BA to date, and the largest psychological study for depression ever conducted, Professor David Richards and his team at the University of Exeter randomly consigned 440 participants to either BA or cognitive behavioural therapy (CBT), the “gold-standard” treatment for depression. What they discovered was that BA (a therapy revived from the 1950s) was as effective in treating depression as CBT. In both groups the recovery rate was about 65 to 70 per cent. To put this into perspective, routine British health services have a recovery rate of about 45 per cent, Richards explains.
Where this gets exciting is that BA requires far less training than CBT. “It’s 20 per cent cheaper than CBT,” Richards says. “That means we can get more mental-health bang for our mental-health buck. The second argument for this is its simplicity relative to other treatments available.” Behavioural activation is easy for people of all ages and cultures to understand and implement. “We’ve got people using BA in adolescence and for perinatal depression.”
“What happens when you’re feeling depressed is you stop interacting with the world in quite the same way,” Richards says. “They’re kind of shrinking into a small world which is really devoid of opportunities for that positive reinforcement whether it be fun or accomplishment or whatever. It’s a really isolating disorder. If you stop doing stuff, then you get miserable.”
In essence, the therapy involves working with a counsellor to construct a program of activities designed to create positively reinforcing, rewarding experiences identified as meaningful to the client. These can be as simple as preparing a cooked meal or reading a book, Richards says. “Even just a small walk or clearing up, doing a bit of washing, stupid little things like that, can actually make you go, ‘Okay, that’s great, my place isn’t a mess anymore.’ These things really matter to people. You get a sense of pride, you get a sense of achievement, and a sense of I’ve really done something now.”
In effect, BA combines studies on activities that help depression (for example, gardening, exercise, creative arts, social clubs) and places them under one umbrella term. It’s also helpful for countering life changes that contribute to depression, such as separation, parenting young children or chronic illness. While most psychological treatments for depression try to change our internal world, BA works from the “outside in” Richards explains.
After a stroke five years ago at the age of 49, Shelagh Brennand was unable to perform her job as a private investigator. She spiralled into depression. “It was a huge life change for me,” Brennand recalls. “It’s a grieving process. You lose your identity and your life.”
Anti-depressants gave Brennand some relief but left her feeling flat. She turned to writing poetry and colouring in to cope. “It makes me feel relaxed when I do a poem no matter if it’s sad or happy. I go into a bit of a zone.” Brennand, who lives on the Sunshine Coast, started posting her poems online to help other stroke survivors. This led to a colouring-in book, A Stroke of Poetry, and charity work including becoming an ambassador for the Stroke Foundation. Like Curnow, Brennand incidentally discovered the benefits of exercise. She hired a personal trainer to lose weight and then took up mountain climbing. Thanks to her activities, her depression was short-lived. “It’s probably a combination of all the three things really – the colour therapy, the poetry, the exercise, and knowing you’re helping others with what you do. It’s given me that focus, that purpose back in life that I lost.”
Richards points out that BA isn’t merely about having fun but about meeting whatever needs are considered important to an individual. “You’re doing things because of words such as achievement, self-satisfaction, accomplishment,” he says. “It’s about who you are and you feeling good about it.”
Depression and anxiety affect about 10 per cent of the global population, according to a 2016 World Health Organisation statement. And Australian Bureau of Statistics figures from 2016 show suicide, closely linked to depression, kills more Australians in the 15 to 44 age bracket than any other cause.
Richards views BA as “an exciting prospect for reducing waiting times and improving access to high-quality depression therapy worldwide. [It] offers hope for countries that are currently struggling with the impact of depression on the health of their peoples and economies.”
He believes training generic health workers and volunteers in BA could increase the prevalence of treatment in those with less access to health services – the undeveloped world, rural populations and the economically disadvantaged within the developed world. “A lot of people think everybody in developed countries gets good access,” Richards says. “That’s not the case.”
“It’s now definitively shown that we have another effective treatment that should be provided to patients. It’s also about patients saying, ‘I want behavioural activation.’ ”
According to Australian practising clinical psychologist and research fellow at Black Dog Institute, Dr Janine Clarke, a key strength of BA is it is less stigmatising. “When depression is addressed in behavioural terms, that is, something that you ‘do’ and not something that you ‘have’, many clients feel liberated from the stigma of mental illness. BA is an extremely palatable treatment approach that makes intuitive sense to patients.”
Its simplicity makes it more accessible for those with language difficulties and intellectual impairments, she adds. It may also appeal more to men. “Men are at high risk of suicide and often reluctant to seek help,” Clarke says. “Research by Black Dog Institute shows that men view participating in enjoyable and rewarding activities as important for staying well and preventing depression. Because BA is potentially less ‘touchy-feely’ than some other psychotherapies, it may provide an attractive treatment approach for depression in this hard-to-reach group.
“It’s time efficient and transportable – able to be delivered via the internet using digital and handheld technologies. Hence, much of the appeal of BA lies in its potential for delivery on a broad scale.” However, Clarke is keen not to dismiss the merits of CBT. “We certainly do not want to pit one therapy against the other,” she says.
“It’s about patient choice,” Richards concludes, although he stresses that for those with serious mental-health conditions, such as bipolar disorder, treatment decisions should not be made without consulting their doctor.
When dealing with mild to moderate depression, he says, “Many people would prefer not to take medication. I think there’s an argument as well for the perseverance of this treatment. You get much less relapse in psychological treatments than you do with drugs. Because obviously people have learnt to behave or think differently. It’s an old-fashioned technology and, guess what, it still works.”
This article was first published in the print edition of The Saturday Paper on Oct 6, 2017 as "Best interests". Subscribe here.