in the treatment of depression, there have been fewpublished and easily
accessible resources that provide an explicit, step-by-step protocol
for the provision of a purely behavioral activation treatment.
To address this gap in the literature, we designed the Brief Behavioral
Activation Treatment for Depression (BATD) (Lejuez, Hopko,
LePage, Hopko,&McNeil, in press), which provides clinicians with a
powerful behavioral intervention to treat depression in a succinct and
parsimonious package. Although the principles and processes underlying
BATD are focused on behavioral activation, cognitive and emotional
processes are not ignored. Moreover, although not directly targeted
for change, these cognitive aspects of depression are presumed
to become more adaptive following behavioral activation procedures
and are assessed frequently across sessions as an index of treatment
gains. Finally, we do not deny the potential effects of resulting covert
changes; we merely assert that activation should be the direct target
for change in a cycle that may lead to the long-term remission of
depression.
The advantages of this protocol lie in its ease of implementation,
including the absence of difficult skills for therapists to acquire. Additionally,
this protocol easily is tailored to the ideographic needs of a
particular patient.Within this structure, patients and practitioners collaborate
to identify individualized target behaviors, goals, and
rewards that serve to reinforce nondepressive or healthy behavior.
Finally, considering the restrictions being imposed by health maintenance
organizations, the time-efficient and cost-effective nature of
BATD makes it a viable treatment option.
We developed BATD to specifically target contextual factors that
affect behavior, using the matching law as a guiding principle (Lejuez
et al., in press). According to the matching law (Hernstein, 1961,
1970), the proportion of behavior allocated to one alternative relative
to a second possible alternative is equal to the proportion of obtained
reinforcers on the first alternative relative to the second alternative.
Applied to clinical depression, the matching law suggests that the relative
frequency of depressed behavior compared with nondepressed
256 BEHAVIOR MODIFICATION / April 2001
(i.e., healthy) behavior is proportional to the relative value of reinforcement
provided for depressed behavior compared with nondepressed
behavior (McDowell, 1982). In other words, depression
persists because (a) reinforcement available for nondepressed behavior
is lowor nonexistent, and/or (b) depressed behavior produces a relatively
high rate of reinforcement. Based on this philosophy, the
behavioral activation treatment for depression is designed to increase
exposure to the positive consequences of healthy behavior, thereby
increasing the likely reoccurrence of such behavior and necessarily
reducing the likelihood of future depressed behavior (see Lejuez et al.,
in press, for amore detailed discussion of the matching law conceptualization
of depression).
Preliminary data examining implementation of BATD within clinical
settings supports its effectiveness. First, in several outpatient case
studies (Hopko, Lejuez, McNeil, & Hopko, 1999; Hopko, LePage,
et al., 1999; Lejuez et al., in press) we have shown sizeable decreases
in the Beck Depression Inventory–II (BDI-II) scores using BATD
(pre-BATD = 29.7; post-BATD = 8.7). More recently, we have been
testing the effectiveness of BATD within an inpatient mental health
facility where inpatients received either BATD or supportive psychotherapy
(Hopko, LePage, et al., 1999). Considering the data presently
available, itwas found that the change in BDI-II scores for individuals
receiving BATD (pre-BATD = 34.6; post-BATD = 18.0) was significantly
greater than that for individuals receiving the standard supportive
therapy typically used within the hospital (pre-therapy = 36.6;
post-therapy = 29.9; t (21) = 2.16, p = .04). In future studies, we are
interested in establishing the utility of BATD when compared with
other psychotherapies and pharmacotherapies. Additionally, although
we have no reason to doubt its applicability across other modalities
(e.g., group therapy) or with other populations (e.g., adolescents),
empirical tests of its generalizability are needed.
A step-by-step patient manual for the implementation of BATD is
provided below. The protocol is intended for distribution to the
patient, with the practitioner serving to facilitate the patient’s progress.
Indeed, the intent is to have the patient take responsibility for
change and to actively participate in the course of therapy, with an
emphasis on work outside of the session. Therefore, the primary role
Lejuez et al. / BEHAVIORAL ACTIVATION 257
of the practitioner is to provide an environment supportive of behavior
change and to ensure that the execution of the treatment occurs at a
reasonable pace and is not overwhelming to the patient. The following
is an example of how the treatment rationale might be introduced to
the patient:
You may not presently feel as though you are able to get much done or
that you are always tired and lack motivation. You also may be waiting
to feel better or think more positively before you become more active
and start participating in activities that once brought you pleasure. As
you know, however, getting yourself to feel better is not an easy thing to
do. Therefore, we’d like you to try something different. The idea of the
treatment we are about to begin is that your thoughts and feelings are
affected by your interactions with others and your overall quality of
life. So, we believe that for you to have more positive thoughts and to
feel better, you must first become more active and put yourself into
more positive situations. Although this will be quite difficult right now,
it will become easier as more and more positive experiences occur. The
treatment requires you to work hard, and I understand that you may be
questioning your ability to make changes at this time in your life, but I
will help you through this process, and we will work at a pace at which
you feel comfortable.
The practitioner should initially provide a highly structured environment
and be fairly directive and supportive. Over the course of treatment,
and determined on an ideographic basis, guidance should gradually
be faded. Throughout treatment, and particularly in the initial
stages, the practitioner also should provide appropriate social reinforcement
for treatment compliance and goal attainment.
Treatment generally consists of approximately 10 to 12 sessions. In
earlier sessions that include an explanation of the treatment rationale,
attaining environmental support, and activity and goal selection, sessions
may take as long as 1 hour (Units 1-3). Over time, as the patient
becomes more skilled at monitoring, sessions may be reduced to
between 15 to 30 minutes. Depending on the progress of therapy and
patient comfort with the protocol, less frequent and even shorter sessions,
as well as telephone contact, may be utilized. Following the
introduction of the treatment rationale, patients should be guided in
the collection of baseline activity level and depressive symptom severity
(Unit 4). As a final step in the preparation for the treatment proto-
258 BEHAVIOR MODIFICATION / April 2001
col, patients should be directed toward the identification of contextual
factors that may be influencing the occurrence of depressed behavior.
This process likely will focus on the identification of reinforcers for
depressed and nondepressed behavior, with special attention to the
behavior of friends and family. Once these basic steps have been
engaged, activities can be selected and placed within the framework
described above (Unit 5). Finally, weekly assessment, planning, and
adjustment are used to ensure that the treatment proceeds successfully
(Unit 6).
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