Running head: REVISED BATD MANUAL Ten Year Revision of the Brief Behavioral Activation Treatment for Depression (BATD): Revised Treatment Manual (BATD-R) C. Lejuez Center for Addictions, Personality, and Emotion Research, University of Maryland Derek R. Hopko University of Tennessee Ron Acierno Medical University of South Carolina Stacey B. Daughters University of Maryland Sherry L.
Pagoto University of Massachusetts Medical School Keywords: Depression, Reinforcement, Activation, Matching Law Address Correspondence to: C. Lejuez Department of Psychology Center for Addictions, Personality, and Emotion Research (CAPER) University of Maryland College Park, MD 20742 E-mail: clejuez@psyc.edu Phone: (301) 405-5932 Fax: (301) 314-9566 1 Abstract Following from the seminal work of Ferster, Lewinsohn, and Jacobson, as well as theory and research on the Matching Law, Lejuez, Hopko, LePage, Hopko, and McNeil (2001) developed a reinforcement-based depression treatment that was brief, uncomplicated, and tied closely to behavioral theory. They called this treatment the Brief Behavioral Activation Treatment for Depression (BATD), and the original manual (Lejuez, Hopko, & Hopko, 2001) was published in this journal. The current manuscript is a revised manual (BATD-R), reflecting key modifications that simplify and clarify key treatment elements, procedures, and treatment forms.
Specific modifications include: (a) greater emphasis on treatment rationale including therapeutic alliance; (b) greater clarity regarding life areas, values, and activities; (c) simplified (and fewer) treatment forms; (d) enhanced procedural details including troubleshooting and concept reviews; and (e) availability of a modified Daily Monitoring Form to accommodate low literacy patients. Following the presentation of the manual, we conclude with a discussion of key barriers in greater depth including strategies for addressing these barriers. 2 Ten Year Revision of the Brief Behavioral Activation Treatment for Depression (BATD): Revised Treatment Manual (BATD-R) Following from the seminal work of Ferster (1973) and Lewinsohn (1974), as well as theory and research on the Matching Law (Herrnstein, 1970; McDowell, 1982), Jacobson et al. (1996) found that the behavioral components of cognitive behavior therapy (CBT) for depression (Beck, Rush, Shaw, & Emery, 1979) performed as well as the full CBT package.
Jacobson et al. (1996) referred to the behavioral component of CBT as Behavioral Activation (BA), and it included a wide range of behavioral strategies across 20 sessions including: (a) monitoring of daily activities; (b) assessment of the pleasure and mastery that is achieved by engaging in a variety of activities; (c) the assignment of increasingly difficult tasks that have the prospect of engendering a sense of pleasure or mastery; (d) cognitive rehearsal of scheduled activities, in which participants imagine themselves engaging in various activities with the intent of finding obstacles to the imagined pleasure or mastery expected from those events; (e) discussion of specific problems (e., difficulty in falling asleep) and the prescription of behavior therapy techniques for dealing with them; and (f) interventions to ameliorate social skills deficits (e., assertiveness, communication skills). From Jacobson et al (1996), Martell, Addis, and Jacobson (2001) and then Martell, Dimidjian, & Hermann-Dunn (2010) provided a more comprehensive BA treatment manual that was expanded to include a primary focus on targeting behavioral avoidance as well as a variety of other related strategies more indirectly related to behavioral activation (e., periodic distraction from problems/unpleasant events, mindfulness training, and self-reinforcement). Lejuez, Hopko, and Hopko (2001) developed a compact 12 session protocol limited to components directly related to behavioral activation including a focus on activity monitoring and scheduling with an idiographic, values-driven1 framework supporting this approach.
In recognition of the findings of Jacobson et al. (1996), Lejuez and colleagues named their approach Brief Behavioral Activation 3 Treatment for Depression (BATD), with the original version of the manual published in this journal. Hopko, Lejuez, Ruggiero, and Eifert (2003) provide a thorough comparison of the treatment components of BA and BATD including strengths and weaknesses, as well as a review of the supportive literature for the two approaches. Comparative effectiveness studies have not been conducted to determine the superiority of either approach, or for which patients each version would be best suited.
However, some have hypothesized that BA may be the treatment of choice in cases of more complicated depression, whereas BATD may be more appropriate in cases where a more straightforward and brief approach is desirable (Kanter, Manos, Busch, & Rusch, 2008; Sturmey, 2009). In addition to conceptual pieces (e., Hopko et al., 2003; Jacobson, Martell, & Dimidjian, 2001; Sturmey, 2009), specialized books (Kanter, Busch, & Rusch, 2009) meta analyses (Cuijpers, van Straten, & Warmerdam, 2007; Ekers, Richards, & Gilbody, 2008; Mazzucchelli, Kane, & Rees, 2009), recent recommendations from clinical guidelines have indicated that behavioral activation is efficacious for treating depression (National Institute of Health and Clinical Excellence; NICE, 2009). Several key large scale randomized clinical trials have indicated that BA is a cost- effective and efficacious alternative to cognitive therapy and antidepressant medication (Dobson et al., 2008; Dimidjian et al. Several trials provide support specific to BATD.
Hopko, Lejuez, LePage, Hopko, and McNeil (2003) showed improved depressive symptoms for patients within an inpatient psychiatric hospital as compared to the treatment as usual at the hospital in a small scale randomized clinical trial. In a second study highlighting the brief nature of BATD, Gawrysiak, Nicholas, and Hopko (2009) showed that a structured single-session of BATD resulted in significant reductions in depression as compared to a no-treatment control for university students with moderate depression symptoms. Several studies also have demonstrated efficacy for BATD for depression in the context of other co-morbid conditions. In addition to 4 case controlled studies of individuals with depression co-morbid with obesity (Pagoto et al., 2008) and cancer (Hopko, Bell, Armento, Hunt, & Lejuez, 2005), two randomized clinical trials support BATD, one among a community-based sample of smokers attempting cessation (MacPherson et al., 2010), and the other among individuals in residential drug treatment (Daughters et al.
In the context of our clinical and research experience with the treatment combined with extensive manual development efforts (including key informant interviews with patients, counselors, and supervisors) useful modifications to the manual have been made. These fit well within the framework of Rounsaville, Carroll, & Onkin (2001) on the stage model of behavior therapies research development. Specifically, we have completed each part of Stage I including (a) pilot/feasibility testing, (b) manual writing, (c) training program development, and (d) adherence/competence measure development. Good progress has been made in Stage II requirements of randomized clinical trials (RCTs) to evaluate efficacy as noted above, with the more recent studies using BATD-R manual (Daughters et al., 2008; Gawrysiak et al., 2009; MacPherson et al.
Moreover, although these studies have not explored mediation, they have shown significant changes compared to a control group in activation and reinforcement- based variables we hypothesize as mediators, with future work planned to formally test mediation. Based on this progress, Stage III work is being conducted which centers on systematically answering key questions of transportability (e., generalizability, implementation, cost-effectiveness) in unique settings including residential drug treatment centers for adults and adolescents, a college orientation program, a junior high school summer scholars program for low income youth, a hospital-based cancer treatment program, as well as international settings including a community health center with Spanish speaking patients and a torture survivors recovery program in the Kurdistan region of Iraq. Presentation of BATD-R In considering the development of BATD, it is important to address the role of functional 5 analysis. Although a comprehensive functional analysis is not included in BATD due to its brevity (Hopko et al 2003), several treatment components fit well within a functional analytic framework.
This is most evident in the selection of activities tied closely to values given the dual focus on 1) identifying positive and negative reinforcers that maintain or strengthen depressive behavior and 2) identifying positive reinforcers that maintain or strengthen healthy behavior across multiple life areas. Establishing values prior to identifying activities helps ensure that selected activities (healthy behaviors) will be positively reinforced over time, by virtue of being connected to values as opposed to being arbitrarily selected. Patients are asked to consider multiple life areas when identifying values and activities to ensure that they increase their access to positive reinforcement in several areas of life rather than in 1 or 2, the latter of which can narrow the opportunities for success. The review of monitoring with planned activities at the start of each session also it tied closely to the principles of functional analysis.
Specifically, the patient and therapist consider planned activities that were not completed and develop a plan for successfully completing these activities in the coming week. Similar to what might be done in a more formal functional analysis, this plan could include selecting smaller more attainable activities in line with the process of shaping or using contracts to address environmental barriers to completing activities by soliciting social support to provide a more supportive environment. Alternatively this plan could include dropping activities (and possibly values) for which the potential positive consequences of completion do not outweigh the negative consequences or where the environmental barriers to completion are not modifiable. The purpose of this manuscript is to provide a revised manual of BATD that reflects modifications over the past 10 years, largely focused on simplifying and clarifying key treatment elements, procedures, and treatment forms for both research and clinical settings.
These changes in no way alter the theoretical underpinnings of the approach but instead are structural in nature to improve delivery and patient acceptability. As a result of these efforts to streamline the 6 protocol, this revised manual (i., BATD-R) 2 provides the treatment in 5 unique sessions and includes 5 additional sessions to allow for concept review and termination/post-treatment planning. Although there has yet to be systematic work comparing different lengths of treatment, this 10 session protocol serves as a useful standard recommendation because it presents the manual in the fewest number of sessions needed to provide all unique material and concept reviews as indicated above. However, additional sessions are certainly not contraindicated, and on the other hand, BATD-R can be modified to include fewer sessions when needed, with studies indicating significant reductions in depression from 6-8 sessions (e., Daughters et al., 2008; MacPherson et al., 2010), and even one study showing some benefits of BATD-R with a single session (Gawrysiak et al.
It is notable that although research protocols require a preset number of sessions, BATD-R also can be used very flexibly in clinical settings with the treatment shortened or extended on a case by case basis given the unique characteristics of the patient and the setting. BATD-R is also quite amenable to be used in conjunction with other approaches in the case of co-morbidity, patient preference, or as supported by clinical judgment. Taken together, BATD-R can be provided in a manualized packaged program with evidence providing support across a range of sessions, but also used flexibly where strict adherence to a manualized protocol is not a requirement. Although streamlining the protocol is a clear goal in BATD-R, the revised manual also was developed with the goal of including: (a) greater emphasis on treatment rationale including therapeutic alliance, (b) greater clarity regarding life areas, values, and activities, (c) simplified (and fewer) treatment forms, (d) enhanced procedural details including troubleshooting and concept reviews, and (e) the availability of a revised Daily Monitoring (with Activity Planning) Form to accommodate low literacy.
We also provide a sample Treatment Adherence Checklist in Appendix 1. As with the original manual, the revised manual is written to be used by both the therapist and patient. As an important procedural note, we recommend that the patient keep the 7 manual and copies of all treatment forms and homework including completed monitoring forms from previous weeks over the course of treatment. This allows patients the opportunity out of session to reflect on their values, associated activities, and changes in daily activities over time.
We also recommend that the therapist make copies of all completed forms and retain them for treatment planning and to provide a back-up if the patient does not bring their manual to session.
