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Depression and behaviour

In the first section you learnt about what depression is, how it differs from normal variation in mood and how it can be recognised and treated. We introduced you to two fictional characters who talked about their individual experiences of depression.

In section two you’ll be learning more about how behaviour can maintain depression but also how behaviour can be the vehicle for changing depression.

Watch Philip’s short intro video to learn more about section two of our BA learning resources.

 

Understanding our behaviour

How behaviour is a chain reaction that can give us or deprive us of emotional rewards.

The A-B-C Cycle

Take a moment to think about your day, or your week.

– What have you been doing?

– Was there anything that you meant to do but avoided, put off or didn’t manage?

– Were there times when you did “nothing”?

Even when you thought you were doing “nothing”, in fact, you did “something”: lying in bed, or staring out of the window, or daydreaming, or ruminating (thinking about something over and over again).

What we do, or don’t do, is summed up with the term “behaviour”.

Generally, our behaviour is driven by lots of different factors, for example, routines we have developed around family and work responsibilities, looking after our health and wellbeing, and our preferences for spending our free time. Some behaviours are habitual – we do them without realising or without having to think about them at a certain day and time. Other behaviours are the result of conscious decisions we make, or goals we want to achieve.

What drives us to do something or avoid it?
Most importantly, what drives us to keep doing something or keep avoiding it?

A cartoon walks through a door…

  1. Through the first door, our cartoon meets someone who gives them a treasure chest (REWARD).
  2. Through the second door, our cartoon meets someone who gives them a kick (PAIN).
  3. Through the third door, our cartoon meets someone who has a magic spell that gives relief from pain but only as long as the cartoon remains by that door (PAIN RELIEF).
  4. Through the fourth door, our cartoon meets nobody and gets nothing (ABSENCE OF REWARD).

Which doors is our cartoon likely to go through again?
Which doors is our cartoon likely to avoid, or not bother going through again?

The point of the story is that the consequences of what we do (reward, pain, pain-relief or reward-absence) drive whether we are likely to do this again or avoid this. Our cartoon is likely to want to walk happily through the first door, avoid the second, use the third if needed, and not bother with the fourth.


Bringing it all together and applying it to depression

The Antecedents-Behaviours-Consequences, or A-B-C, Cycle can help us understand:

  • What maintains unhelpful behaviours that feed into depression.
  • How we can change unhelpful behaviours into more helpful ones to improve depression.

In the next few steps, we will look at the As, Bs and Cs in more detail and elaborate on the application of the A-B-C Cycle for depression.

Over the last week, think of one thing that:

  • You did because you expected it to be enjoyable and fulfilling (REWARD).
  • You avoided because you expected it to be stressful, uncomfortable, difficult or scary (PAIN).
  • You did to stop something unpleasant from happening (RELIEF).
  • You put off doing because you expected it to be tedious, boring and pointless (ABSENCE OF REWARD).

One example could be preparing a large meal. You may have made it because you enjoy cooking (REWARD) or because you argued with your partner about whose turn it was to cook (TO STOP UNPLEASANTNESS). On the contrary, you may have NOT have made it because it would have been stressful or you were too tired (PAIN), or because you don’t enjoy cooking (ABSENCE OF REWARD).

Antecedents

An Antecedent (A), which means “something that comes before”, is a set of circumstances and experiences that comes before a behaviour.

    For example, the antecedent may be that you feel hungry, which makes you eat (behaviour). Of course, our actions are often influenced by more than one antecedent. Our decision to eat, and what to eat, may also be influenced by:

    • The time of day (lunch or dinner time), where we are (we’ve arrived back home from work) and who we are with (hungry children)
    • What we do at the time (go to the kitchen and open the fridge)
    • Our emotional state (happy, bored or upset)
    • Our physical state (tired or energetic)
    • What goes through our mind (“I must prepare something healthy” or “I fancy a pizza”).

    Sometimes antecedents may conflict so that they trigger different or opposing courses of behaviour. For instance, feeling hungry stimulates us to eat, but thinking that we must lose weight may prompt us to prepare a salad, having hungry children may lead us to making a big bowl of pasta (with or without the salad!) and feeling tired after a long day’s work may make us order a takeaway pizza in the end…


    Five types of antecedents

Over to you

Looking back over the last week, can you pick something that happened that stands out in your mind for some reason; it may have been surprising, enjoyable or upsetting.

Can you describe:

  • Where were you and with whom?
  • What were you doing at the time?
  • How were you feeling at the time?
  • Did you notice any bodily sensations?
  • What thoughts or images were going through your mind?

The process above is the starting point of what we call “recent incident analysis” in psychological therapy.

Behaviours

A behaviour (B) is how we respond to antecedents.

Covert vs Overt Behaviours

Behaviours can be overt (obvious) or covert (hidden). Overt behaviours are “physical” actions (e.g. asking for reassurance, staying in bed, bursting into tears), whereas covert behaviours are usually “mental” actions (e.g. praying, positive self-talk, ruminating).

So how do we know whether a behaviour is helpful or unhelpful?

The answer comes from asking another question: “Does the behaviour maintain the problem or does the behaviour help us change it?”
If the behaviour maintains the problem, then it is unhelpful and we focus on reducing, removing or replacing that behaviour. If the behaviour helps us change the problem, then we need to encourage and increase that behaviour.


Different types of behaviour

Avoidance: Not entering into a situation because we feel worried, scared or overwhelmed; we may avoid something that we find uncomfortable, unpleasant or irritating. An example is avoiding crowded places from fear of feeling trapped or avoiding social occasions from fear of being judged or because they involve people whom we do not like.

Escape: Running away from a situation to get relief from unpleasant feelings or to prevent something bad from happening. An example is leaving a restaurant or a party early for feeling anxious. Another example that many children relate to is seeing a spider and running out of the room.

Safety behaviours: Doing something to help us cope with a situation or to prevent something unpleasant from happening. Think of the last time you forgot your mobile phone at home and went somewhere – work, school, social event – without it.

Withdrawal: Stopping something that we used to do because we no longer enjoy it, or because we are not motivated to do it, or because we feel guilty for doing it. A typical response when we feel low and “can’t be bothered” is to stop seeing people. We may also stop doing things we enjoy because there are too many things we have to do out of necessity and duty.

Rituals: Repetitive actions that we do to get comfort and reassurance, or because we think they would prevent something bad from happening. One example, which many people relate to, is pushing the door after they lock it “just to make sure” it does not open, when, in fact, it is obviously shut because it is locked.

Habits: Repetitive actions that are difficult to predict or control that have no apparent purpose but happen automatically or in response to a specific cue. For example, nail bitting or leg shaking when we are nervous or bored.

Impulsive behaviours: Actions that we do in response to an urge, usually in anticipation of the thrill and pleasure we may get. Think of the last time you made an impulsive purchase, or when you ate or drank something because of an urge rather than a more long-standing intention.

Ruminations: Thinking something over and over again, mostly because we are worried about it or because we feel strongly about it. A relatable example for many people is going to bed at night and not being able to switch off because they are thinking of all the things they haven’t done or that they have to do the following day. Another example of rumination is going over and over again in our minds what we said or could have said, what other people said and what they meant during past conversations.

Over to you

When we were thinking about antecedents, you looked back at your week, and you picked an event. It was something that happened that stands out in your mind for some reason; it may have been something surprising, enjoyable, or upsetting. You described where you were and with whom, what you were doing at the time, how were you feeling at the time, and what was going through your mind.

Now think of HOW you responded to that event

Your response may have been a way of coping with it or making it stop (if it was something unpleasant) or a way of making the most out of it (if it was something enjoyable). Your response may have been to run away, or just go through the motions passively and in a detached way.
Think of what you did, or what you avoided doing, whether your responses were covert or overt, helpful, or unhelpful.

  • Do you relate to any of the types of behaviours we describe here?
  • Do you catch yourself, or people you live with, avoiding, escaping or withdrawing from situations?
  • Or ruminating?
  • Or doing something impulsive or out of habit?
  • Having safety behaviours or rituals?

Consequences

A consequence (C) is what happens as a result of a behaviour.

Consequences are important because they influence whether a behaviour is repeated and strengthened, or whether it is reduced and stopped.

When we talk about “consequences” here, we mean feelings. These can be positive feelings, such as pleasure, a sense of achievement, high energy, feeling closer to someone, as well as negative feelings, such as feeling scared, angry, hopeless or tired. (Note that feelings can be bodily sensations and emotions).

You can think of positive feelings as “rewards” and negative feelings as “pain” (pain in a metaphorical or literal sense).

Behaviours that lead to rewards, or prevent pain, are more likely to be repeated (they are reinforced).

Behaviours that have no rewards or that lead to pain, are more likely to be reduced or avoided.

 

Four mechanisms that drive behaviour

 

The process of repeating a behaviour because it either leads to a reward or because it prevents pain is called reinforcement. Avoiding something because we expect it to lead to “pain” is driven by punishment, whereas the process of stopping or reducing activities because they are not rewarding is due to absence of positive reinforcement.

Below we look at each of these behavioural mechanisms in turn:

Positive reinforcement

    • Behaviours that are repeated because they lead to a reward are positively reinforced. Having hobbies, socialising and completing projects are typical activities that are positively reinforced because they are enjoyable and give people a sense of accomplishment when they are finished.

Negative reinforcement

    • Behaviours that are repeated because they prevent pain are negatively reinforced. Asking for reassurance and using distraction are typical behaviours that are negatively reinforced because we use them to prevent feeling overwhelmed or getting anxious; they tend to work short-term but paradoxically they end up reinforcing the feelings they try to prevent.

Punishment

    • Avoidance is a typical behaviour driven by “painful” consequences. Pain here is used in its metaphorical sense as an unpleasant and negative feeling that stops us from doing things that we may find difficult or stressful. Pain can also be used literally, when physical pain or exhaustion stop us from engaging in productive or pleasant activities.

Absence of positive reinforcement

    • Absence of positive reinforcement leads to stopping or reducing activities because we see no point in them or we no longer care. Typically in depression, people lose interest and pleasure in day-to-day life; as a consequence, they stop doing things or do less of what they used to enjoy.

In the next activity we will look at how all of this may be applied to depression and, in doing so, introduce you to Sarah. Sarah is a fictional character representing typical experiences of depression.

Understanding the role of behaviour in depression

Understand how low mood affects the way we act and how our actions maintain low mood.

Applying the A-B-C model

Let’s look at how the ABC model may apply in a specific person’s experiences and circumstances.

Please watch the video above which will introduce you to Sarah. Sarah is a fictional character representing typical experiences of depression.

Applying the ABC model to Sarah’s experiences and circumstances:

Can you give examples of behaviours that feed into depression?

Think of examples of things that people may do, or may avoid doing, in day-to-day life when they feel low, tired, unmotivated and hopeless.

The vicious circle of depression

Common symptoms of depression, such as feelings of hopelessness, loss of energy and enjoyment in life, and lack of motivation, can lead to changes in usual behaviours. These changes can disconnect us from sources of positive reinforcement in our lives.

Remember our cartoon earlier?

A cartoon walks through four different doors on separate occasions. Different things happen as the cartoon walks through each door. The doors are a metaphor for behaviour.

  • Can you map each door to one of the four mechanisms that drive behaviour?
  • Can you identify which behaviours are likely to maintain depression?
  1. Our cartoon meets someone who gives them a treasure chest.
    Meeting someone who gives our cartoon a treasure chest is an analogy for positive reinforcement; having a reward by walking through that door is likely to encourage the cartoon to go back. In this case, the door is a metaphor for an emotionally rewarding activity, i.e. something that leads to enjoyment or a sense of achievement. In the context of behaviour, walking through a “rewarding” door can be helpful.
  2. Our cartoon meets someone who gives them a kick.
    Meeting someone who gives our cartoon a kick sounds like punishment; having pain by walking through that door is likely to make the cartoon avoid that door. Even worse, a “painful” door may discourage our cartoon from walking through ANY door, including the one with the treasure.
    Avoiding things that we find emotionally or physically painful because of depression, for example, due to bad memories, self-reproach, or exhaustion, is a natural response; however, avoidance can indirectly maintain depression because it deprives us of opportunities to have emotionally rewarding experiences and to connect with people and things that matter.
  3. Our cartoon meets someone who has a magic spell that gives relief from pain but only as long as the cartoon remains by that door.
    Our cartoon meeting someone with a magic spell that gives relief from pain is a metaphor for negative reinforcement; the cartoon is likely to walk through that door every time they need the magic spell to make emotional or physical pain disappear, but as soon as they move away from the door, the pain reappears. Standing by, or repeatedly walking through the “pain relief” door prevents our cartoon from reaching the door with the treasure.
    In the context of depression, distraction or procrastination may temporarily work to provide relief from feeling overwhelmed or from doing something difficult or tedious. Distraction and procrastination simply delay bad/negative feelings and indirectly maintain depression because they deprive us of opportunities to experience good/positive feelings.
  4.  Our cartoon meets nobody and gets nothing.
    Meeting nobody and getting nothing is a metaphor for the absence of any emotional rewards, or else, the absence of positive reinforcement. This makes the cartoon more likely to stop walking through that door; not because they deliberately avoid it, but because there is not point to it and they no longer care.
    Absence of positive reinforcement is the key mechanism that maintains depression and the “nobody and nothing” door is a metaphor that illustrates how depression makes people stop or reduce activities because they see no point in them or they no longer care.

Absence of positive reinforcement is the key mechanism that maintains depression

It is natural to want to feel ready until we do something, and to want to conserve our energies until we are ready to do it. It is also natural to avoid doing something that we expect to be unpleasant or not worth the effort. In depression, a person may never feel ready or have the energy to do something or may find many things pointless; this leads to behaviours dominated by avoidance and procrastination.

The result of avoidance and procrastination is that the person is missing out on opportunities for positive reinforcement. Without the opportunities to focus their attention on something purposeful and rewarding, they may also find themselves thinking repeatedly and unproductively about aspects of their life they are finding frustrating or worrying, leading to depressive rumination.

Avoidance, procrastination, rumination and missed opportunities for positive reinforcement feed and perpetuate depression: the less we do, the worse we feel; the worse we feel, the less we do.


Let’s return to Sarah

Sarah continues to feel overwhelmed, tired, hopeless, and ashamed. She does not cook meals for herself regularly, so she has more problems managing her diabetes and her general physical health is deteriorating. She continues to neglect the house and her appearance, so she continues to put her daughter off from visiting her. The fewer things she does, and the more things she avoids, the more isolated and ill she becomes. This is the vicious circle of depression.

Download a pdf of the vicious circle of depression

Breaking the vicious circle of depression

Let’s return to Sarah

What happens if despite feeling tired and not having an appetite, Sarah thinks about what her doctor told her and does make herself a meal?

Although it felt hard to do, Sarah decided to make herself a very simple meal. In this way, Sarah’s action – making a meal – was motivated by a purpose and not by her low mood.

Afterwards, Sarah realised that she hadn’t been thinking about her troubles whilst she was occupied making her meal. She thought that her daughter Rachael and her doctor would be pleased that she’d eaten, and she noticed that she was feeling a bit better in herself. She felt a sense of achievement for making her meal because it took effort to do it. As she sat down again, she decided that she’d call her daughter to tell her that she’d made herself a meal and to find out how her grandson Lewis was doing. As she picked up the phone, she was looking forward to the call.

We can see how Sarah is starting to introduce sources of positive reinforcement in her life by making a meal and phoning her daughter.

To break the cycle of depression, Sarah acted driven by a purpose rather than by her low mood.

Over to you

Can you think of activities in your day-to-day life that you do because you are motivated by a purpose and not by your mood?

A simple example is getting up in cold and dark winter’s morning to take the children to school or to go to work. Your mood tells you to stay warm in bed but your purpose makes you get up.

Can you think of activities in your day-to-day life that you put off doing because your mood tells you so?

In this case, how can you replace mood-driven behaviour with purpose driven behaviour?

If you feel anxious about your job, or if you reproach yourself for not achieving enough at work, you may give up things that you do for pleasure or as a rest from working. Your mood (anxiety or self-reproach) tells you that you have to keep on working and working without any pleasure or rest. A purpose-driven behaviour will be to do an activity that you will enjoy and make you feel good about yourself other than as a worker.

Making the most of good feelings

When we are struggling with depression it can be easy for our brain to focus on negative thoughts and bad memories.

Paradoxically, when people start talking about how depression affects them and are becoming more aware of their ABCs associated with their depression, they may enter a spiral of negative rumination. It is difficult to “just stop” ruminating, but we can interrupt the rumination with the help of a positive memory.

  • Take a few moments to think about a good memory.
  • Perhaps one that could be repeated in the future.
  • Now apply the A-B-C to this positive memory.

Wrapping up Section 2

A summary of what has been covered this week and a quiz relating to this.

Take-home message

This week we have looked at the ABC cycle of behaviour and how this can be applied to everyday life and specifically to the experience of depression.

We have explored the concepts of negative and positive reinforcement and have seen how depression can get people stuck in a vicious circle of feeling low, doing less and depriving themselves of emotional rewards. It is possible to break out of this cycle through purpose-driven behaviour rather than mood-driven behaviour.

The take-home message is:

  • We don’t have to wait till we feel better in order to do something rewarding.

  • We can do something rewarding in order to feel better.


Take a moment to reflect on the ideas that have been explored in this section:

  • What did you find particularly interesting?
  • What are the main things you have discovered?
  • Were there any parts you found difficult or unhelpful?
  • What would you like to find out more about?
  • What have you learnt that you might put into practice?

Test you knowledge

This short quiz aims to help you think about what you’ve been learning and if there is anything you’d like to go back to review or explore further.

The quiz is optional as a learning tool, and it is not an exam.

Use a pen and paper to record your answers.

Question 1: What do the letters A, B and C stand for in the A-B-C cycle?

  1. Anticipation, Behaviour, Consequence
  2. Antecedent, Behaviour, Cost
  3. Anticipation, Behaviour, Cost
  4. Antecedent, Behaviour, Consequence

Question 2: How does positive reinforcement relate to depression?

  1. Positive reinforcement maintains depression
  2. Absence of positive reinforcement maintains depression
  3. Increasing positive reinforcement can help depression
  4. Reducing positive reinforcement can help depression

Question 3: What are the objectives of behavioural activation?

Select all the answers you think are correct.
  1. To encourage avoidance and procrastination
  2. To override avoidance and procrastination
  3. To increase positively reinforced behaviours
  4. To increase negatively reinforced behaviours

Question 4: How behaviours are reinforced

Fill in the correct missing word.

Safety behaviours are _________ly reinforced because they are ways of preventing or coping with anxiety. Rewarding activities that give pleasure and a sense of achievement are _________ly reinforced.

Quiz answers

We hope you’ve enjoyed section one of our BA learning resources. In the final section you’ll learn more about how behavioural activation works and look at the evidence for its effectiveness.

Let’s progress to the final section

Behavioural activation for depression