Carl Lejuez’s Reformulation of Behavioral Activation

 

By Lynn Mollick

 

            On Sunday September 28, NJ-ACT members gathered at the Holiday Inn Clark to hear Dr. Carl Lejuez speak about Behavioral Activation (BA).

            Dr. Lejuez began by describing a cognitive behavioral model of depression based on the concept of “delay discounting” – the concept that immediate consequences are more powerful than future consequences because future consequences are uncertain. Thus, depressed symptoms occur because patients choose immediately reinforcing avoidance behaviors over healthy behaviors. The immediate consequences of many healthy behaviors are stressful, and therefore punishing, while the positive consequences of healthy behavior are often delayed, uncertain, and therefore less effective.

            BA diminishes depressed behavior by making healthy behavior immediately rewarding. BA accomplishes this by identifying patients’ valued life goals, their cherished dreams for themselves. The patient and therapist then identify behaviors that are steps toward the patient’s valued life goals. Viewing healthy behaviors as steps toward valued life goals, provides positive reinforcement immediately following the healthy behavior.

            BA is not about “being busy”; BA is about engaging in behaviors that are immediately reinforcing because they are steps toward the patient’s valued life goals.

 

Identifying the Patient’s Valued Life Goals

            Dr. Lejuez advocated discussing patients’ values in the first session. He suggested first assessing patient functioning in 6 areas of life:

            1. Relationships

            2. School/career

            3. Hobbies/recreation/helping others.

            4. Mind/body/spirituality

            5. Daily responsibilities, and

            6) other issues

            After identifying what the patient values in each of these life areas, learn about the patient’s functioning in each area. Then work with patients to identify activities that patients believe will be steps toward their valued life goals.

            Specific activities suggested should always be enjoyable, important or both. In developing these assignments, keep in mind:

            1. Successive approximation -- breaking complex or difficult behaviors into smaller, more achievable steps;

            2. Fading support -- gradually reducing the help provided to patients in planning and structuring their behaviors.

            3. Functional analysis when the patient doesn’t complete activities.           

 

The Behavioral Monitoring Form:

            BA’s flagship interventions utilize the Behavior Monitoring Form, an hour-by-hour record of what the patient does with ratings of the importance of each activity and the enjoyment the patient experienced. Patients also rate their overall depression at the end of each day. 

            The Behavior Monitoring Form is useful because:

            1. It increases patients’ awareness of their depressed behavior patterns.

                        a. When is depression most or least intense?

                        b. Are any activities high in importance and but low in enjoyment?  

            These are often activities done for others’ benefit.

                        c. What are the activities with low importance and low enjoyment?

            2. The Behavioral Monitoring Form enables patients to see the connection between what they do and how they feel.

            3) The Form helps define what activities are important and/or enjoyable.

            Patients should work on the Behavior Monitoring Form after each activity, or by bedtime each day at the latest. Tell patients that some information is better than none, and that the form “helps me get to know what you think, feel, and do.” If patients don’t complete the form, pick a specific day and ask the patient to complete the form in session for that day. Choosing a recent day and a more distant one demonstrates that immediate recording increases accuracy. 

            Initially, patients should fill out the form without making changes in their behavior. In later sessions, look at the form and help the patient develop plans of how and when to add more enjoyable activities and more activities that are steps toward their valued life goals.

            To get started, Dr. Lejuez suggested making a list of 15 activities that are steps toward valued life goals and rank ordering them. Choose the easiest first. Patients should plan one or several activities each week. If patients complete the planned activity, they should circle it on the form. If they do not, they should cross it out and write what they actually did.

 

Facilitating strategies:

            1. When planning a stressful activity, schedule something relaxing first.

            2. Teach patients to practice emotion regulation after a stressful activity.

            3. When patients do not complete a scheduled activity, help patients plan what they can do to help them complete the activity in the future. 

 

Other Clinical Considerations

            BA is based on the concept that when behavior changes, thoughts and feelings change as well. BA includes discussion of patients’ thoughts and feelings, and showing patients how their thoughts, feelings and behaviors influence each other.

            BA is effective as a stand-alone treatment and also as an add-on to other treatments. It has been validated for various age groups – children, adults, and older adults – and for depressed patients with additional problems – grief, drug and alcohol abuse, smoking, obesity, cancer, and for patients in primary care settings.

            In response to numerous requests, we are pleased to report that Carl Lejuez’s last name is pronounced “Le-Zhway.”