In The Sound of Music, on a particularly scary night, Maria (Julie Andrews) reminds the children to think of their “favorite things” to keep their spirits high. Aside from being the sort of movie that can always bring joy, Maria hit on an important theme in depression treatment.
One of the defining symptoms of Major Depressive Disorder is “diminished interest or pleasure” in activities (American Psychiatric Association, 2013). Generally, when feeling depressed, people will either stop engaging in activities altogether, or keep engaging but find them less enjoyable than previously. For example, someone who has played soccer for years may not try out for the team in a new season. Another person who enjoys bingeing TV shows may continue to watch TV, but no longer find it captivating.
Behavioral Activation is an evidence-based therapy treatment designed with this symptom set in mind. Essentially, behavioral activation involves re-engaging in avoided activities and social interactions to provide positive reinforcement and an improved mood.
I’m going to overly simplify Behavioral Activation to give some guidance toward improving mood. Of course, a qualified mental health professional with training in Behavioral Activation would be most appropriate to guide someone through this treatment program.
Behavioral Activation involves scheduling engagement in pleasurable and mastery activities with the hopes of improving mood in the moment. By creating change in mood at the micro level, it aims to reinforce macro change in overall mood (therefore, reducing depression).
Pleasurable activities are designed to instill happiness/joy/pure little kid fun. This is where “my favorite things” comes in. Examples of pleasurable activities are:
Going on a nature walk Going out for ice cream Petting an animal
Singing along to The Sound of Music Birdwatching
Meeting up with a friend Visiting a theme park Playing pickleball
Now, of course, we cannot just live a life of pure pleasure. If we could, maybe we would be less depressed. (Or maybe more depressed, if not living toward a purpose?)
This is where mastery activities come in. Mastery activities may not necessarily be highly enjoyable in the moment, but can still improve mood through a sense of achievement. For example, guitar is “fun,” but it is not fun to sit around hurting your fingers and stumbling through a chord. So, while the sense of mastery achieved while learning to play guitar should improve your mood, it might not feel particularly pleasant at certain times. Checking items off the to-do list can be another mastery activity. Calling the dentist to set up an appointment is not fun, but it sure is a relief to get that task completed. Other examples include:
Brushing your teeth twice a day Making a therapy appointment Running errands
Eating 2-3 servings of fruit per day Practicing free throws
Cleaning your room Waking up on time Learning Spanish
As you can also probably see, any activity could be conceptualized as pleasurable or mastery, depending on how it is used. Using “walking” as an example: going on a slow-paced walk in a park would likely be a pleasurable activity, while working toward a goal of 10,000 steps per day would likely be a mastery activity.
In therapy, I ask depressed individuals to engage in one pleasurable and one mastery activity per day. I usually help them schedule it out, so there is more chance for success. Now, the activities could stay the same every day or change, depending on your preference. Here is an example schedule:
Pro Tip: If you have trouble scheduling and picking the activities, I’d suggest making it easy on yourself. For example, you could write down potential mastery activities (e.g., to-do list items) and draw your selection from a jar each day. This way, you are not responsible for the decision, and all you have to do is complete the activity.
The last important principle of Behavioral Activation involves rating your mood before and after the activity. We want to be collecting some data and making sure these activities are having the intended effect. Also, people who are feeling depressed tend to rate their mood as overall bad, rather than recognizing moment-by-moment changes. Tracking ratings might look like this:
I recommend assessing your mood every two weeks (first measurement before beginning Behavioral Activation), using the PHQ-9 (or a similar depression rating), to determine whether your overall mood is improving. When completing the PHQ-9, if your depression rating is higher than “mild” and/or you are having suicidal thoughts, please complete this program with a mental health professional.
Lastly, I recommend setting a completion goal and rewarding yourself. For example, let’s say week one, you want to complete your pleasurable and mastery activities 5/7 days. If you hit that goal, maybe you reward yourself with your favorite meal or finally subscribing to Hulu.
And there you have it! One of the best tools we have for treating depression can actually be broken down into fairly simple steps. When I guide patients through this program, I generally see significant mood improvements in the first 2-4 weeks. It can be incredibly effective.
Learn more about depression here.
Please let me know what you thought of this article in the comments below.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596