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A new study examined therapeutic skills use after discharge from a partial hospital.

More use of behavioral activation skills predicted continued depression improvement.

Using skills to feel good in the short term was not the best way to support continued improvement in symptoms.

Intensive treatment programs, such as partial hospitals or intensive outpatient programs, provide more support than outpatient care. When entering an intensive treatment program, a patient’s typical schedules and responsibilities are put aside to focus on their mental health. Intensive programs often require attendance for most of the day every weekday and last a week or more. Patients are able to focus entirely on learning new skills and ways to improve their mental health. However, when they leave the program, they are thrust back into the same, often hectic or stressful lives that they came from, with all the same responsibilities and time constraints they faced before. This period immediately following discharge is critical for patients to implement the skills they have learned in treatment.

While we know that therapy skill use during treatment is associated with improved mental health outcomes (Hundt et al., 2013; Jackson et al., 2023), little is known about what happens with skill use after people leave treatment. For example, it is unclear whether skill use continues to be associated with symptom improvement after treatment ends or whether the same or different skills are needed following treatment. In the case of intensive treatment programs, certain skills might be most useful for stabilization in acute distress while others might be better employed after the acute distress subsides and when there is more time to master the skill.

Our research group at McLean Hospital recently conducted a study to answer some of these questions about skill use following discharge from an intensive treatment program. We were interested in how patients use skills without the structure and oversight of a treatment program or therapist. This study, appearing soon in Cognitive Therapy and Research, examined which skills predicted continued recovery following discharge. It also examined a novel question: does how people feel after using a skill matter for their continued improvement?

Upon discharge from a partial hospital program, we asked patients to download an app that presented questions throughout the day about emotions and skills use. After two weeks of these surveys, patients reported their depression symptoms. First, we tallied up the number of times patients used the different skills learned in treatment. Second, we examined the relationships between therapeutic skills use and positive and negative emotions within each participant. Finally, we used a machine learning algorithm to predict which people continued to get better after discharge versus who stayed the same or got worse. Here are some of the main findings:

Patients who frequently used behavioral activation were 24% more likely to continue to improve after they left the program. Behavioral activation involves purposefully engaging in valued or positive activities even when motivation or mood is low, thereby introducing opportunities to feel positive emotions or to limit depression’s effects on one’s goals and values.

Patients who often felt positive emotions shortly after using cognitive behavioral therapy skills were 16% more likely to not improve post-discharge.

Behavioral activation is a gold-standard treatment for depression; thus, it is not surprising that people who used more behavioral activation skills continued to improve after discharge. However, our finding that people who experienced more momentary positive emotions after using CBT skills were less likely to improve during the two weeks following intensive treatment requires some explanation.

Therapy skills that improve your mood in the moment should be good for your overall mental health, right? However, this study suggests that short-term relief or positive emotions may be a less effective way to use skills. Though behavioral activation is designed to improve mood, it may be unpleasant in the short term. For instance, making yourself go to the gym when you’re feeling low might feel really difficult and negative in the short term, even if you end up being glad that you went. Immediate positive affect while engaging in behavioral activation might indicate that the patient is not choosing the most challenging or rewarding activities. For instance, patients might choose the easiest skill rather than one that is going to be the most helpful, e.g., choosing to reframe how one is thinking about a recent argument when a more effective strategy might be communicating effectively with the person with whom one was quarreling. In this situation, the reframing may serve an avoidance function preventing the individual from solving problems effectively.

What Is Cognitive Behavioral Therapy?

Take our Your Mental Health Today Test

Find a therapist who practices CBT

These findings suggest that in the weeks after discharge from a partial hospital program, behavioral activation may be an especially helpful skill for addressing depression symptoms. Additionally, the most helpful implementation of CBT skills may feel unpleasant in the short term, but beneficial in the long term, akin to physical exercise.

Shaan McGhie contributed to this post. Shaan is a Ph.D. student in the Department of Psychology at Harvard University.

McGhie, S.F., Forgeard, M., Fan, K., McNally, R.J., Beard, C. (In press). What Happens After Intensive Treatment? Post-Discharge Skill Use and Affect as Predictors of Depression Outcomes. Cognitive Research and Therapy.

Hundt, N. E., Mignogna, J., Underhill, C., & Cully, J. A. (2013). The Relationship Between Use of CBT Skills and Depression Treatment Outcome: A Theoretical and Methodological Review of the Literature. Behavior Therapy, 44(1), 12–26. https://doi.org/10.1016/j.beth.2012.10.001

Jackson, H. M., Calear, A. L., Batterham, P. J., Ohan, J. L., Farmer, G. M., & Farrer, L. M. (2023). Skill Enactment and Knowledge Acquisition in Digital Cognitive Behavioral Therapy for Depression and Anxiety: Systematic Review of Randomized Controlled Trials. Journal of Medical Internet Research, 25, e44673. https://doi.org/10.2196/44673

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