Treat Your Depression from the Outside In

envolve center for health behavior change

This post originally appeared on the Envolve PeopleCare Blog

At any given time, 1 in 12 Americans meet the criteria for a diagnosable clinical depression, not including the millions more suffering from milder forms of depression. It is the primary cause of disability for those between 15 and 44 years of age, and by 2020, depression will be second only to heart disease in terms of global disease burden. 

Despite how many people and their families are affected by depression, there is no cure. There are effective treatments for depression; however, many people don’t have the time and money to do long-term therapy or don’t want to take medication (30-50 percent of people do not seek treatment at all).

Fortunately, a major breakthrough may lie in a simple form of therapy called behavioral activation. Even though behavioral activation has been around in some version for over 40 years, it was mainly viewed just as a part of the “Gold standard” for depression treatment ‒ cognitive behavioral therapy.

However, a number of recent studies have found that behavioral activation, on its own, is just as effective at treating depression as cognitive behavioral therapy treatment ‒ except cheaper and easier. And, just as effective as antidepressant medications for some people.

So, what is behavioral activation and why is it so great?

The vast majority of depression treatments, like cognitive behavioral therapy, are “inside-out” therapies focused on changing thoughts (inside) so that behaviors (outside) can change in response.

Behavioral activation works the opposite way around – it’s an “outside-in” therapy where daily activities and experiences (outside) can change thoughts and mood (inside). By increasing activities that people value and get positive feedback from, the cycle of depression and withdrawal can be reversed.

“Outside-in” approach: Actions can cause emotions

People’s general assumption is that thoughts and feelings cause actions. If you are feeling sad and tired, you may choose to stay home instead of going to a friend’s birthday party. In other words, if you are motivated to do something, you’ll do it … but you have to be motivated first.

It turns out that often this isn’t how it actually works. Often our attitudes and feelings are caused by our behaviors – not the other way around. For example, if you had forced yourself to go to that friend’s birthday party, you would most likely feel better and more energetic. Even if you were never motivated to go in the first place. Social psychologists call this “self-perception” and have documented this “you are what you do” effect in many different areas.

When depressed people are asked to describe their day-to-day lives, there are clear patterns that emerge. Generally, their weeks are full of boring, stressful tasks with almost no positive experiences or sense of achievement. Even though working through emotions is important for people with depression, there is usually a faster way to feel better by simply changing behavior. To feel less depressed, behave like you’re less depressed.

How to try behavioral activation – even if you’re not depressed

Like any other treatment, the best way to do behavioral activation is with a therapist who can walk you through the process. If you are seeing someone already or looking for a new therapist, ask them about it.

However, if you just aren’t into therapy right now or feel more stressed than depressed, you can take some of the main ideas of behavioral activation and apply them to your life starting today. Here is how to get started:

behavioral activation for treating depression

Step 1: Pre-commit

Start by identifying a few small positive events that you can add to your week. Make a list including some that are more for fun (see a movie) and others that are things you need to get done (cook dinner), and schedule them on a specific date and time on your calendar. This is called an implementation intention, which will increase the chances that you’ll follow through.

To further increase the likelihood that you will not back out, you can pick an accountability buddy. Ask a friend to join you, agree to report back to a therapist about your progress, or even to post your success on Facebook.

Step 2: Rethink your emotions and “just do it”

Sometimes when we are depressed we tend to do things like avoid a social event because we are anxious about being able to hold a conversation, or skip a walk because we feel too fatigued. In caveman days these feelings of anxiety and fatigue may have been good warning signs about things to avoid. But in depression, these emotions are false alarms. It’s completely normal to feel unhappy, anxious or scared when you try something different or push through fatigue. These feelings don’t mean anything bad; they are just symptoms of depression, and they don’t have to get in the way of your life. In fact, the more that you engage in meaningful activities, especially when you don’t feel up to it, the less noticeable they will become.

Step 3: Enjoy the upward spiral

We have all heard about the dreaded downward spiral of depression where sadness makes us withdrawn and isolated, cutting off all social support and joy, and worsening depression. Adding positive events into your daily routine can stop this downward spiral. So, don’t wait on internal motivation. Get started by scheduling and completing some activities. Over time, as you continue to do more of those pleasant and meaningful activities, you might start to even enjoy and look forward to them, creating an upward spiral of positive emotions.

Julie M. Miller, PhD, is a senior behavioral researcher at the Center for Advanced Hindsight at Duke University. She works with the Envolve Center’s Behavioral Economics team, which incorporates behavioral economics and social science into health-related behavioral modification programs. Julie’s work blends behavioral economics and clinical health psychology to develop interventions that improve adherence to medical recommendations, QOL, provider-patient relationships, medical decision making, and overall health and wellness.


The Envolve Center for Health Behavior Change™ is a partnership between the Brown School at Washington University in St. Louis, The Center for Advanced Hindsight at Duke University and Centene Corporation. The Envolve Center projects use behavioral science insights to improve health outcomes, working for evidence-based changes at every stage in the process.