Activation as Treatment for Depression

PEARLS counseling helped Mrs. Barbara Clark learn problem-solving techniques that help her manage depression. Today she is happier, healthier, living in a pleasant home, and more engaged with friends and in her community.

Humans have been plagued by depression from the beginning time. Over the centuries, depression has been called "melancholia," "black bile," and "a morose outlook on life." Depression wasn't recognized as a diagnosable affliction until the late 19th century.

Many kinds of treatments have been used over the ages to remedy what early psychiatrists called depressive neurosis: water immersion, spinning to induce dizziness, unusual diets, enemas, and even lobotomies. Sigmund Freud used psychoanalysis (therapist talking to a patient reclining on a couch).

In the 1950s, brain research provided another understanding of depression. Researchers concluded that depression may result in a chemical imbalance in the brain that significantly affects how we think, feel, and act. This opened up the field of drug therapy as a promising treatment that provides relief of symptoms of depression. Since then, medications such as Welbutrin, Effexor, and Prozac have been used to treat the affliction of depression.

There is new evidence, however, that something as simple as behavioral activation—helping a person find ways to increase physical, social, pleasant/enjoyable activities and learn problem-solving techniques—has a significant effect on decreasing depression, whether one is taking antidepressant medications or not. Behavioral activation has been shown to cut one’s degree of depression by half.

PEARLS (Program to Encourage Active Rewarding Lives) is an activation counseling program that came out of a research study conducted by the University of Washington's Health Promotion Research Center between 2000 and 2003. The study was supported by the work of clinical staff at Aging and Disability Services (ADS) and Senior Services. Due to its proven success here and across the country, PEARLS is now offered by ADS, Senior Services, the African American Elders Program, and the International Drop-in Center.

For an example of how much activation counseling can help, take Queen Anne resident Barbara Clark. Sixty-four years old, Mrs. Clark spent her life as a homemaker, raising five daughters (now grown), operating a day care service so she could raise her daughters at home, and later working as a cook in a senior residential retirement home.

When Mrs. Clark was referred to the PEARLS program, she lived in a basement apartment and showed many signs of depression. She stayed in bed for long periods of time, but didn't sleep well and didn’t feel rested. She ate too much, lost interest in doing things, and didn't go out much due to arthritic pain in her legs. Mr. Clark had recently passed away. About her husband, she said, "I lost a companion—a way of life." One daughter lived nearby but was aloof, uncommunicative, and not helpful.

Mrs. Clark felt overwhelmed by financial problems, which worsened after her husband's death. After paying her rent, she had little to no spending money. "I felt so bad," she said. "I needed to do something to fill the void."

Signs of Depression

Depression can begin suddenly, as a result of a specific event, or come on slowly over time, without apparent cause. The medical symptoms of depression include two or more weeks of:

  • Feeling down or sad or hopeless
  • Having little interest or pleasure in doing things
  • Experiencing changes in appetite or sleep patterns
  • Feeling tired or having little energy
  • Having trouble concentrating, keeping mind focused even when interested in a topic on TV or newspaper
  • Feeling bad about oneself, like a failure or that you've let yourself or family down
  • Thoughts of being better off dead or even suicidal

If you or someone close to you is experiencing those symptoms, talk with your health care provider or case manager, if you have one.

For free, confidential and professional information and referrals, contact Senior Information & Assistance (age 60+) or King County 2-1-1 (all ages).

Mrs. Clark was a good candidate for the PEARLS program. In spite of her problems, she would say, "I need to move on. I need to find something to look forward to." With help from a PEARLS counselor, Mrs. Clark began to separate her problems and define how each one caused her to feel so down and discouraged. Then she set achievable goals for each problem. For example, she wanted to "have enough income to meet my obligations," "find ways to meet new people," "increase physical activity," and "find a lower rent apartment." And then she identified possible solutions and developed a plan to carry out each solution she chose.

Over the seven months that Mrs. Clark met with a PEARLS counselor, she had ups and downs, advances and setbacks, but she made slow and steady progress on her goals.

To start, Mrs. Clark mustered the energy to ride the bus to Capitol Hill and resume caring for her P-Patch plot, working on it to the extent she felt able. When she cut Swiss chard and donated it to the food bank, she said it felt good to contribute to society. When she could, she also cared for a friend who has Multiple Sclerosis. Mrs. Clark found that doing something for others, even though she is quite limited herself, made her feel better about herself and boosted her mood.

Mrs. Clark looked into joining the Ballard Senior Center. She also followed up on an application she'd made long before for a Section 8 housing subsidy through the Seattle Housing Authority. To save money she discontinued her landline phone and cable, and used a cell phone with limited minutes, even though that meant no TV and no intercom from the entrance of her apartment.

Finally Mrs. Clark received notice that her name came up on the Section 8 housing subsidy list and, with the help of her case manager, she found and moved into a SHAG apartment. Her rent subsidy reduced her payment by nearly one-third. She received help packing and organizing her possessions from Paula Murphy of the Family Support Group. Day laborers from the Millionair Club helped with her move.

These days, Mrs. Clark can be found living in a well-lit south-facing seventh floor apartment. Not only is the apartment bright and sunny, so is her disposition. Her improvements are apparent: she is fully dressed in a bright colored outfit, she smiles more, and she walks with less effort because she has visibly lost weight. Living with people her age provides opportunities to make new friends, and she plans on joining the local senior center.

"I feel so much better!" she says. "You showed me how to solve problems. Words can't express what this program has done for me."

Depression is treatable with behavioral activation planning. The first step in reversing depression is recognizing it. All too often, people feel that they should be able to handle whatever is troubling them on their own. They don’t want to admit they might have depression and that it's interfering with initiative, decision-making, and follow-through with personal care. Sometimes depression interferes with follow-through on treatment advised for medical problems.

Depression may be an emotion that results naturally from stresses, disappointments or losses in life. But if feelings last over two weeks, what was once a passing emotion may have become an illness. Depression has medical symptoms, as other illnesses do (see sidebar above).

PEARLS counselor and trainer Carl Kaiser (right) has helped dozens of individuals learn problem-solving techniques and increase enjoyment.

For more information about PEARLS, visit If you are a veteran or a veteran's spouse or domestic partner, you are especially encouraged to consider whether PEARLS may be helpful (click here).

—Contributor Carl Kaiser, MSW is a PEARLS counselor with Aging and Disability Services, the Area Agency on Aging for Seattle-King County. Through the University of Washington's Training Xchange, Carl teaches PEARLS workshops at the UW School of Social Work and other locations across the country.