Combatting Depression with Behavioral Activation

CBT, or cognitive behavioral therapy, is the most widely practiced evidence-based therapeutic model in the treatment of depression. It’s possible for therapists to focus either on cognition or behavior. ‘B’ represents behavior-based motivations, including behavioral activation. Very often, when people slide into depression, they let go of the things which make them feel good. This is because depression creates apathy. Just getting out of bed can be a challenge, let alone carving time for extracurricular activities.

Behavioral activation involves reconnecting with things that bring joy, purpose, and meaning. It might include very small daily tasks. If these bring a sense of achievement, then they’re relevant as treatment. As a therapist, it’s your job to help your client work out what makes them feel good. And, what doesn’t. This might mean remembering a hobby from childhood. It could involve tackling something which has always been tempting, but challenging. It might also mean exploring something entirely new. This can help your client see how they can grow through the things they engage with, as they slowly rebuild their capacity for joy.

Creating a Program of Meaningful and Supportive Motivations

The research shows that behavioral activation is as effective as medication. It’s also slightly superior to cognitive therapy in the treatment of depression. But it needs to be managed carefully. To identify and encourage activities that are the most beneficial, you need to work with your client to strike the right balance. Behavioral activation should balance activities that spark joy with tasks that require mastery. Everyone will have a unique combination of activities that can be used to target depression. These should build positive reinforcement and shift the focus from cognition and feelings, to behavior and environment.

To develop a program of behavioral activation, work with your client to track what activities make them feel better and which make them feel worse. You can have them keep a journal to note their mood before and after different activities. The journal will help you both to recognize moments of growth and strength. It will also help you identify moments of disconnection and negativity.

Behavioral activation is essentially a twofold process. Over time, you’ll be able to define a schedule of activities that cultivate a greater sense of mastery and enjoyment. You’ll also be able to clearly define what makes feelings of depression worse, and consciously avoid these. That will help make time for more activating behaviors. You increase positive reinforcement through supportive activities and replace negative avoidant behaviors with rewarding behaviors.

Recruiting Support: Social Circles and Feedback Informed Progress

Of course, this doesn’t just work overnight. It takes time and determination. Often, clients will need to push through with activities to see the benefits. Work with your clients to agree on markers for progress. This is essential for helping your client move towards positive reinforcement. You might have them recruit the help of a friend or relative to keep them on track. Enlisting the support of their social circle will help keep them accountable. It will also mean there’s more encouragement available to your client outside of your one on one time. The combined impact of your sessions, support of a social network, and increased capacity for joy and meaning can help your client to climb back out of depression.

ACEs and Intergenerational Trauma: A Public Health Crisis

Acute Childhood Traumas, or ACEs, are the biggest public health issue today. Studies have shown that ACEs are responsible for 7/10 deaths in the US. They reduce life expectancy by 20 years. They affect brain development, immune and hormonal systems, and DNA encoding. ACEs are caused by abuse, neglect, and toxic stress. These are the tragic repercussions for families who are struggling with mental illness and substance dependence. They are also infective. A child that has suffered from ACEs is more likely to inflict trauma on their children later in life. This perpetuates the cycle of intergenerational trauma.

ACEs and Neurodevelopment

For a long time, ACEs were not recognized or diagnosed in children who presented with neurodevelopmental issues. Children with ACEs are often diagnosed with ADHD and prescribed drugs but this doesn’t deal with the root of the problem. Understanding how ACEs affect childhood development can help you to find other ways to support children. ACEs can cause long-term damage as they can inhibit the prefrontal cortex. This handles executive function, impulse control, and learning. MRIs have shown that ACEs also cause measurable changes to the amygdala, which is our fear center. Damage to the amygdala increases high-risk behavior. This is a dangerous cocktail when mixed with other developmental issues, especially in adolescence. Children who experience ACEs are also more likely to develop cancer and heart issues later in life.

Scaling ACEs to Understand Intergenerational Trauma

Before 1998, the severity and proclivity of ACEs were not known. Nor was the impact of health outcomes resulting from them. A seminal study by Felitti et al. researched ACEs to better understand the scale of their occurrence. And to learn more about health outcomes resulting from them. The groundbreaking study showed that 67% of the US population had experienced at least one ACE. 12.6% (1 in 8) had experienced four or more ACEs. The study also showed for the first time that childhood trauma has a significant impact on long-range adult outcomes. It began the investigation into intergenerational trauma.

The risk factor for ACEs and potential resilience against them may be linked to positive/negative childhood experiences of parents. These can be carried forward into future parenting practices. Parents who encounter many ACEs often exhibit symptoms of PTSD. This is a mediator of risk in the intergenerational transmission of ACEs. The mechanisms of intergenerational trauma are not fully understood. But its existence is undeniable.

In its simplest form, intergenerational trauma reflects parents using the same maladaptive parenting styles that they experienced growing up. Intergenerational trauma is also influenced by the impact of environmental stressors like poverty, unsafe living conditions, and systemic prejudices.

Whilst these contributors to intergenerational trauma are vast, they can still be overcome. Trauma-related behavior within individual families can be dismantled through nurturing relationships, enriching activities, and creating safer environments. The earlier an intervention can occur the better so that children avoid adverse development. This is the way to break the cycle of intergenerational trauma.

Defining Toolkits to Recognize and Work with ACEs

ACEs pose the biggest threat to public health in the US. Effective clinical treatment protocols and toolkits should be defined and provided to public health professionals. If you work with children and families affected by ACEs and intergenerational trauma, here are some things to consider:

• Use the ACEs questionnaire to screen for signs of trauma. This is a great starting point in addressing root causes, instead of diagnosing conditions or prescribing medication. It will open up the conversation about adverse conditions and intergenerational trauma. You can find different versions of this through The American Academy of Pediatrics.

• Adopt a trauma-informed approach with parents, as well as children. Be careful of language which indicates any sense of blame. Instead of, “what’s the matter with you?” ask “did something happen to you?”.

• Adopt early intervention and wellness approaches for the whole family. Promote local group/family exercise programs, yoga, and mindfulness communities. Provide information about parenting skills, nutrition, and self-care.

• Educate families about the impact of toxic stress. You might provide leaflets or websites about this, hold a community meet-up, invite specialists to talk.

Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. (1998) “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study.” Am J Prev Med;14(4): pp. 245-58.