Finding His Wings
Frank was stuck, his life going nowhere fast. (Not his real name.) It was not for a lack of effort: a well-educated man in his early 40s, he had tried several forms of psychotherapy to get back on track after impulsively quitting his high-paid but life-sucking commercial real estate job years earlier. But month after month, immobilized, Frank watched his bank balance dwindle, and he became severely depressed. When I first saw him in my private office for a psychiatric evaluation a decade ago, Frank clearly met criteria for major depression, with low mood, poor sleep, feelings of hopelessness and suicidal thoughts.
So I started Frank on an antidepressant medication, a selective serotonin reuptake inhibitor (SSRI) called sertraline. Within eight weeks his mood, sleep and other symptoms had improved. But he was still barely functional. For months he remained unemployed, sitting at home with his pet African grey parrots, which he adored, only leaving his apartment for doctors' appointments.
What to do? Frank had had years of traditional psychodynamic (“talk”) therapy without much improvement: understanding the psychological origins of his inertia, however valuable, did not enable him to make meaningful changes. Similarly, cognitive therapy, which guides patients to reframe their thinking, had helped Frank to be somewhat less pessimistic about the possibility of changing his life but had not made a dent in his procrastination or avoidance. This pattern is not unusual in patients with depression: their symptoms improve with medication, but they still can't get off the couch.
Casting about for treatment options that might help Frank, I came across an intriguing approach: behavioral-activation (BA) therapy. A stripped-down form of cognitive-behavioral therapy (CBT), it focuses primarily on changing behaviors rather than thoughts. BA therapists ask patients to track their daily activities and encourage them to spend more time each day doing things they enjoy. The theory behind BA therapy for depression is that the disorder stems from decreased exposure to environmental rewards and that patients' negative thoughts and avoidance worsen in the absence of satisfying activities. This keeps them trapped in a cycle of misery and dysfunction.
One could describe BA as a Nike form of therapy, guided by the dictum “Just Do It.” Simplistic though it may sound, it can be remarkably powerful. A 2006 randomized, controlled study of 241 depressed patients found, for instance, that BA was at least as effective as antidepressant medication—plus patients were more likely to stick with it—and that it was much more effective than cognitive therapy, with a 56 percent versus 36 percent success rate for those with severe symptoms. The challenge—and art—of BA is working closely with patients to get them to identify rewarding pursuits and then to change daily behavior even on a gradual basis, building on small improvements to make more meaningful changes. This can be quite difficult with patients, like Frank, who are psychologically stuck in the mud.
I referred Frank to Dr. V., whom I found through a local clinic specializing in CBT. “The BA approach doesn't entirely ignore thoughts,” he told me when I called to make a referral. “For instance, one common thought among people who are depressed is, ‘I need to feel better before I can make changes in my life.' Whereas as a BA therapist, I would say, ‘Start making the changes now, and you will likely feel better.'”
As a therapist trained in psychodynamic therapy, which relies on words, many words, I had become accustomed to often waiting months, even years, for behavior to change, and the in-your-face BA approach, however appealing, was initially jarring to me. But things were desperate for Frank; something needed to be done.
“Okay, let's give it a try,” I said.
Because Frank wanted—needed—to go back to work, Dr. V. initially focused on helping him to update his rusty job skills and begin networking for new opportunities. Frank did so, but progress was excruciatingly slow. Then one day, after six to eight weekly BA sessions, he told Dr. V. that after feeling a burst of energy, he had gone shopping for lumber and carpentry tools. Moreover, he had built a bench, something he had wanted to do for months. Dr. V. was pleased, although this was not directly related to Frank's employment goals.
The next week Frank mentioned that he had used leftovers from his bench project to make a “gym” for his parrots to play on. He showed Dr. V. a photograph: rather than a crude piece of work, it had a beautifully curved shape, with perches and swings. Dr. V. was blown away by what looked like a high-end piece of art and suggested that he spend more time doing what clearly gave him great satisfaction.
Over the following weeks the newly energetic Frank created one elegantly designed bird item after another, which he photographed and listed for sale on the Web. Orders rapidly arrived, and in the coming months Frank launched a new career. After Googling “bird accessories,” Dr. V. was amazed by how Frank's creations outshone those of his competitors, who tended to build clunky kitsch. In contrast, his work was sophisticated and well crafted. It invariably received the highest praise from a growing base of customers. Frank's biggest problem was keeping up with orders. In therapy he and Dr. V. discussed whether he should raise prices because slim profit margins made it hard to cover his living costs. The therapy continued, now focused on the challenges of managing a growing business.
Frank's case—of a sudden burst of activity after prolonged inertia—is not unique: researchers have described many cases of what has been termed “sudden gains” with BA therapy as well as other forms of treatment for depression. A 2012 study led by Kallio Hunnicutt-Ferguson of Northwestern University suggests that about a third of patients treated with BA will experience such gains, in which a slow trajectory is followed by rapid improvement. Research led by Gabriel Dichter of the University of North Carolina at Chapel Hill, using functional magnetic resonance imaging, shows that BA therapy causes reactivation of the brain's reward circuitry, which involves the nucleus accumbens and the neurotransmitter dopamine. Depression is characterized by decreased activity in those areas of the brain and by increased ruminations and negative thoughts—overactivation of brain areas related to self-thoughts and internal focus, such as the default mode network. In fact, new research suggests that SSRI medications often do not improve the depressed brain's sluggish reward circuitry. BA therapy may be a specific way of reactivating reward circuitry as a part of recovery from depression.
This possibility led me—along with several colleagues—to conduct a pilot study of BA with 16 patients with major depression who, like Frank, had responded to medication but could not restart their work life. The study, published last year in Comprehensive Psychiatry, found that 69 percent (11 patients) were subsequently able to increase their work hours, find a new job or, like Frank, create their own business. Why this sudden activation occurs in some BA patients while others linger in a seemingly interminable limbo is a question I continue to explore.
When I see Frank these days, he seems in many ways to be a different person than he was a few years ago. Recently, for the first time in a decade, he began dating. Though still vulnerable to recurrences of low mood and pessimism, he is enthusiastic and energetic and shows initiative and creativity. He is clearly engaged in the world again in a meaningful way.
--Originally published: Scientific American Online, July 2016.