Behavior Modification http://bmo.com/ Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised Treatment Manual C. Hopko, Ron Acierno, Stacey B. Daughters and Sherry L. Pagoto Behav Modif 2011 35: 111 DOI: 10.1177/0145445510390929 The online version of this article can be found at: http://bmo.com/content/35/2/111 Published by: http://www.com Additional services and information for Behavior Modification can be found at: Email Alerts: http://bmo.com/cgi/alerts Subscriptions: http://bmo.com/subscriptions Reprints: http://www.nav Permissions: http://www.nav Citations: http://bmo.html Downloaded from bmo.com at UNIV OF TENNESSEE on March 8, 2011 390929 90929Lejuez et al.Behavior Modification BMO35210.1177/01454455103 Behavior Modification 35(2) 111–161 Ten Year Revision © The Author(s) 2011 Reprints and permission: http://www.
of the Brief sagepub.1177/0145445510390929 Behavioral Activation http://bmo.com Treatment for Depression: Revised Treatment Manual C. Hopko2, Ron Acierno3, Stacey B. Daughters1, and Sherry L. Pagoto4 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 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 depres- sion (BATD), and the original manual was published in this journal. The cur- rent 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; 1 University of Maryland, College Park, MD, USA 2 University of Tennessee, Knoxville, TN, USA 3 Medical University of South Carolina, Charleston, SC, USA 4 University of Massachusetts Medical School, Worceter, MA, USA Corresponding Author: C. Lejuez, Department of Psychology, Center for Addictions, Personality, and Emotion Research (CAPER), University of Maryland, College Park, MD 20742 Email: clejuez@psyc.edu Downloaded from bmo.com at UNIV OF TENNESSEE on March 8, 2011 112 Behavior Modiication 35(2) (d) enhanced procedural details, including troubleshooting and concept reviews; and (e) availability of a modified Daily Monitoring Form to accom- modate low literacy patients.
Following the presentation of the manual, the authors conclude with a discussion of the key barriers in greater depth, including strategies for addressing these barriers. Keywords depression, reinforcement, activation, matching law 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 cog- nitive behavior therapy (CBT) for depression (Beck, Rush, Shaw, & Emery, 1979) performed as well as the full CBT package. Jacobson et al.
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 and communication skills). From Jacobson et al. (1996), Martell, Addis, and Jacobson (2001) and then Martell, Dimidjian, and Hermann-Dunn (2010) provided a more com- prehensive 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 BA (e., periodic distraction from prob- lems or unpleasant events, mindfulness training, and self-reinforcement). Lejuez, Hopko, and Hopko (2001) developed a compact 12 session protocol limited to components directly related to BA, 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., Lejuez and colleagues (2001) named their approach brief behavioral Downloaded from bmo.com at UNIV OF TENNESSEE on March 8, 2011 Lejuez et al. 113 activation treatment for depression (BATD), with the original version of the manual published in this journal. Hopko, Lejuez, Ruggiero, and Eifert (2003) provided a thorough compari- son 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 patient’s each ver- sion 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), and meta-analyses (Cuijpers, van Straten, & Warmerdam, 2007; Ekers, Richards, & Gilbody, 2008; Mazzucchelli, Kane, & Rees, 2009), recent recommendations from clinical guidelines have indicated that BA is efficacious for treating depression (National Institute of Health and Clinical Excellence [NICE], 2009). Several key large-scale,randomized clinical trials (RCTs) have indicated that BA is a cost-effective and efficacious alternative to cognitive therapy and antidepressant medication (Dimidjian et al., 2006; Dobson 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 with the treat- ment as usual at the hospital in a small-scale RCT. In a second study high- lighting 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 with a nontreatment control for univer- sity students with moderate depression symptoms. Several studies also have demonstrated efficacy for BATD for depression in the context of other comorbid conditions. In addition to case-controlled studies of individuals with depression comorbid with obesity (Pagoto et al., 2008) and cancer (Hopko, Bell, Armento, Hunt, & Lejuez, 2005), two RCTs 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 the key informant interviews with patients, counselors, and supervisors), useful modifications to the manual have been made. These fit Downloaded from bmo.com at UNIV OF TENNESSEE on March 8, 2011 114 Behavior Modiication 35(2) well within the framework of Rounsaville, Carroll, and Onkin (2001) on the stage model of behavior therapies research development. Specifically, evi- dence for BATD has been provided for each part of Stage I, including (a) pilot/feasibility testing, (b) manual writing, (c) training program develop- ment, and (d) adherence/competence measure development. Good progress has been made in Stage II requirements of RCTs to evaluate efficacy as noted above, with the more recent studies using revised BATD (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 with a control group in activation and reinforcement-based variables hypothesized as mediators, with future work planned to formally test mediation. On the basis of this progress, Stage III work is being conducted, which centers on systematically answering the key questions of transportability (e., generalizability, implementation, and 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. In considering the development of BATD, it is important to address the role of functional analysis. Although a comprehensive functional analysis is not included in BATD because of the brevity of this treatment approach (Hopko et al., 2003), several treatment components fit well within a func- tional analytic framework.
This is most evident in the selection of activities tied closely to values given the dual focus on (a) identifying positive and negative reinforcers that maintain or strengthen depressive behavior and (b) 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 one or two, the latter of which can narrow the opportunities for success. The review of moni- toring with planned activities at the start of each session also tied it 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 Downloaded from bmo.com at UNIV OF TENNESSEE on March 8, 2011 Lejuez et al. 115 selecting smaller, more attainable activities in line with the process of shap- ing or using contracts to address environmental barriers in completing activi- ties by soliciting social support to provide a more supportive environment. Alternatively, this plan could include dropping activities (and possibly val- ues) for which the potential positive consequences of completion do not out- weigh the negative consequences or where the environmental barriers to completion are not modifiable.
Presentation of BATD-R The purpose of this article is to provide a revised manual of BATD that reflects modifications over the past 10 years, largely focused on simplifying and clarifying the 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 protocol, this revised manual (i., BATD-R)2 provides the treatment in five unique sessions and includes five additional sessions to allow for concept review and termination/posttreatment 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, addi- tional sessions are certainly not contraindicated, and BATD-R can be modi- fied to include fewer sessions when needed, with studies indicating significant reductions in depression from 6 to 8 sessions (e., Daughters et al., 2008; MacPherson et al., 2010) and one study even 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 short- ened 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 comorbidity, patient prefer- ence, or as supported by clinical judgment. Taken together, BATD-R can be provided in a manualized packaged program with evidence providing sup- port across a range of sessions, it 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 Downloaded from bmo.