Behavioral Activation

Strategies for the

Treatment of PTSD
 Acknowledgments
Amy Wagner, PhD
Portland VAMC

Sona Dimidjian, PhD,

MIRECC fellow, Seattle VAMC

Lisa Roberts, PhD

Former MIRECC fellow, Viterion, inc.

Christopher Martell, PhD

University of Washington
Private Practice
 Origins of Behavioral Activation
 BA as an application of reinforcement theory to the treatment
of depression (e.g., Lewinsohn, 1974)

 The behavioral component of cognitive therapy treatment for

depression (Beck, 1976)

 BA is an independently effective intervention for depression

(e.g., Dimidjian et al., 2006; Jacobson et al., 1996)

 BA has evolved into a stand-alone behavioral treatment for

Major Depressive Disorder (see Martell, Addis and Jacobson,
2001)
 What is Behavioral Activation?
 Structured, brief psychosocial approach

 Based on premise that problems in vulnerable

individuals' lives and behavioral responses reduce ability
to experience positive reward from their environments

 Aims to systematically increase activation such that

patients may experience greater contact with sources of
reward in their lives and solve life problems

 Focuses directly on activation and on processes that

inhibit activation, such as escape and avoidance
behaviors and ruminative thinking
 Key Elements of BA
 Behavioral case conceptualization
 Functional analysis
 Activity monitoring and scheduling
 Emphasis on avoidance patterns
 Emphasis on routine regulation
 Behavioral strategies for targeting worry or
rumination
 Goals are specific to the individual (not
necessarily pleasant events)
 Course of BA
 Orient to treatment
 Treatment rationale, including conceptualization of
psychological distress and primary treatment
strategies
 Role of therapist/patient
 Develop treatment goals
 Behavioral analyses
 Repeated application of activation and
engagement strategies
 Troubleshooting
 Treatment review and relapse prevention
 Structure of Sessions
 Set collaborative agenda
 Review homework
 Review weekly activities
 Troubleshoot problem behaviors
 Assign new homework
 Ask for feedback
 Presentation of Treatment
Rationale
 Emphasize relationships between environment,
mood (or anxiety) and activity
 Highlight vicious cycle that can develop between
depressed mood, withdrawal/avoidance, and
worsened mood (or anxiety)
 Suggest activation as a tool to break this cycle
and support problem solving
 Emphasize an “outside  in” approach: act
according to a plan or goal rather than a feeling
or internal state
 BA Activity Chart
 Central tool of BA
 Uses
 Monitor baseline assessment of activity
 Monitor mood and intensity ratings
 Monitor mastery and pleasure ratings
 Monitor breadth or restriction of activity
 Monitor range of feelings
 Schedule activation assignments
 Evaluate progress
 Rationale for Applying BA to PTSD
 Veteran’s preferences for treatment approaches-
(e.g, Johnson & Lubin 1997)

 PTSD and Depression

 High rates of co-morbidity-(Orsillo et al., 1996)

 Common features:
 Poor quality of life
 Decreased physical activity and poor health behaviors
 Passive/avoidant style coping
 Restricted social/interpersonal functioning
 Decreased participation in pleasurable activities
 Absence of positive mood states and lack of future-oriented
thinking
 Cognitive Behavioral
Models of PTSD
 Exposure to a negative (traumatic) event
represents classical conditioning and can
produce a change in the individual’s view of
him/herself and the world

 Anxiety responses generalize over time, such

that any number of situations or triggers induce
a trauma-related response

 Avoidance behaviors perpetuate the learned

stress-response and may inform an individual’s
sense of self-efficacy
 Traditional CBT Approaches to
PTSD Treatment
 Exposure based therapies often directly
target re-experiencing, avoidance of
reminders/discussions/thoughts of the
trauma, and hyperarousal symptoms of
PTSD

 Cognitive strategies address self-schemas

and personal scripts, viewing these beliefs
to be an obstacle to change
 CBT Conceptualization of PTSD

Prior Life Functioning Traumatic Events (s) Symptoms

*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological

Restricted Range of Behavior

Less Rewarding Life
 Traditional CBT Treatment for PTSD

Prior Life Functioning Traumatic Events (s) Symptoms

*Affective (Mood)
*Avoidance Behaviors
Traditional CBT Therapy *Cognitive
Focus: Learn coping skills to *Physiological
decrease arousal symptoms; revisit
the traumatic event until it no longer
produces arousal; address trauma- Restricted Range of Behavior
related schemas Less Rewarding Life

Goals
Decrease symptom severity in order
to increase functioning
 Behavioral Activation for PTSD
Conceptualization

Prior Life Functioning Traumatic Events (s) Symptoms

*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological

Behavioral Activation
Focus: Present centered therapy Restricted Range of Behavior
Working from the outside-in Less Rewarding Life

Goals
*Broadening behavior
*Defining values & achieving goals
*More fulfilling life
 Support for BA as a PTSD
Treatment

 Clinical case studies: BA improves PTSD

and co-morbid Major Depression-Mulick et al.,
2004

 BA is superior to treatment as usual for

recently traumatized population-Wagner et al.,
2006
 Open Trial of BA for Chronic PTSD
Jakupcak et al., 2006

Participants Enrolled N=11

10 men; 1 woman; All Participants were White

Age M(SD) 51.2 (12.65)

Education M(SD) 15 (2)
Vietnam era 9
Post Vietnam 2
 Trauma Exposure and
Symptom Profiles
 Trauma type
 8 VN Vets-Combat
 1 VN Vet-Training Accident
 1 Female-Military Sexual Assault
 1 Post VN era Vet-Peace Keeping (sniper fire; mass
graves)
 Depression, Pain Symptoms, and Compensation
 4 Major Depression/3 dystymia/1 etoh dependence,
remission
 7 Chronic pain
 7 Actively seeking service connection for PTSD
 Outcome Measures
 Clinician Administered PTSD Scale (CAPS)
Blake et al., 1990

 The PTSD Checklist (PCL)

Weathers et al., 1993

 Beck Depression Inventory (BDI)

Beck & Steer, 1987

 Quality of Life Inventory (QOLI)

Frisch, 1994
 Attrition

 Dropped out (n = 1; travel)

 Completed 15 of 16 sessions; lost to

follow up (n = 1)
 Symptom Severity
One-tailed Paired t-test
Pre Post t (df) Hedge’s
g
M SD M SD _____

CAPS 75 (22) 60 (24) 2.47 (8)* .58

PCL 52 (13) 48 (20) 1.00 (9) .38
BDI 26 (15) 22 (17) 0.86 (9) .30
QOLI -.88 (1.6) .11 (1.4) -2.10 (8) -.61

*p < .05
 Individual Change Scores
 CAPS; reliable change at |9| points
 Five of nine of participants showed improvement

 PCL; reliable change at |5| points

 Six of ten showed improvement; 1 deteriorated

 BDI; reliable change at |5| points

 four of ten showed improvement; four deteriorated

 QOLI; reliable change at |.7| points

 Four of nine showed improvement
 Case Example (“non-responder”)
 VN veteran, heavy combat exposure
 Chronic, vivid re-experiencing symptoms
 Was previously functioning in occupational roles
despite PTSD symptoms
 No history of PTSD treatment

 Current stressors: Death of parents, lay-offs,

financial, health concerns and chronic pain (related
to service)
 Severe Depression
 Veteran’s values and goals
 Values:
 Reparation*
 Providing for families (children*)

 Self-Reliance

 Goals:
 Resume work
 Provide for family members

 Improve health (related to first two goals)

 Vicious Circle
 Lack of employment
 Lack of financial resources
 Inability to $ support families
 Decreased visits with grandchildren
 Increased depression
 Decreased motivation for health/wellness
 Increased physical pain
 Difficulties seeking employment opportunities
(health related)
 Example Assignments
 Diet
 Walking (failures and successes)
 Employment seeking
 Talk to friends and associates
 Submit job applications (not only in desired field)
 Begin work (not necessarily only in desired field)
 Spend time with grandchildren (telephone, visits
with or without bringing ‘gifts’)
 Outcomes
 No change in PTSD symptom severity
 No reliable change in depression scores
 Increase in quality of life scores

 Lost over 20 lbs

 Lowered high blood pressure
 Returned to work (incrementally moving toward
desired positions)
 Improved ability to provide financial support
 Increased time spent with family members
Increasing non-symptom experiences

PTSD
Depression
Chronic Pain
Increasing non-symptom experiences

PTSD
Depression
Chronic Pain
 Address common myths about
activation and change
 Will-power or “Nike” model of change
 Too similar to “just get over it”
 Address common myths about
activation and change
Emphasize
 Role of the therapist
 Focused activation based on careful
behavioral analyses
 Graded task assignment

 Difficulty of change
 Discussion, Questions, and
Future Directions
 BA may have potential as a treatment for PTSD and
Chronic Pain symptoms, especially to address quality of life

 BA may be an appropriate, first line intervention as part of a

stepped care approach to treating recently returning
combat veterans

 Initiated open trial of BA for recently returning combat

veterans with PTSD delivered in a Primary Care Clinic

 Planned randomized, multi-site study for returning combat

veterans
 Workshop overview
 Basic epidemiology and patient characteristics
 A model of integrated care for OIF/OEF veterans
 Federal and State collaboration in Washington State
 An integrated model of primary stepped care at VA
Puget Sound, Seattle
 Adapting evidence-based PTSD treatments in
secondary prevention efforts for OIF/OEF veterans
 Specific Clinical Challenges

 Fitness for Duty Recommendations

 Confidentiality

 Documentation
VA/DoD Clinical Practice Guideline for Acute Stress
Disorder and PTSD

http://www.oqp.med.va.gov/cpg/PTSD/
PTSD_Base.htm
 Soldier/Veteran Self-Assessment
http://www.pdhealth.mil/mhsa.asp

 Voluntary, anonymous, self-directed

 PTSD
 Depression
 ETOH
 Bipolar disorder
 GAD
 Results and resources at end of assessment
 The Iraq War Clinician’s Guide
http://www.ncptsd.va.gov/war/guide/index.html

 Assessment guidelines
 Treating medical casualty evacuees
 Treating the traumatized Amputee
 Primary care based treatment of Iraq veterans
 Military sexual trauma
 Assessment and treatment of anger
 Treatment of traumatic grief
 Substance abuse
 Impact of deployment on family members
 The Iraq War Clinician’s Guide
http://www.ncptsd.va.gov/war/guide/index.html

Information for Veterans/Family

 War zone-related stress reactions: what veterans
and family members need to know
 Depression
 Stress, trauma, and alcohol/drug use
 Coping with sleep problems
 Coping with traumatic stress reactions
 Homecoming: dealing with changes and
expectations
 Homecoming: Tips for reunion
 Resilience Training in OIF/OEF Returnees
National Center for PTSD

 Coping with transition stress

 Improving sleep
 Managing stress
 Dealing with anger
 Reintegrating
 Psychological First Aid
http://www.ncptsd.va.gov/pfa/PFA.html

 Contact and engagement

 Safety and comfort
 Stabilization
 Information gathering: identify needs and concerns
 Practical assistance
 Connection with social supports
 Information on coping
 Linkage with collaborative services
 Battlemind Training
http://www.armyg1.army.mil/hr/dcs/Annex/Battlemind%20Training%20II%20Briefing
%20Speaker%20Notes.ppt

 Buddies (cohesion) vs. withdrawal

 Aggressive driving (combat) vs. defensive driving
 Accountability vs. control
 Discipline and ordering vs. conflict
 Targeted vs. inappropriate aggression
 Lethally armed vs. “locked and loaded” at home
 Emotional control vs. anger/detatchment
 Tactical awareness vs. hypervigilance
 The alcohol transition
 Myths vs. facts of mental health