Behavioral Activation
for Depression and PTSD
Amy Wagner, Ph.D.
Portland VAMC
Key Collaborators:

Matthew Jakupcak, Ph.D. (Seattle VA)
Christopher Martell, Ph.D. (UW)
 Sona Dimidjian, Ph.D. (UC Boulder)
 Miles McFall, Ph.D. (Seattle VA)

Behavioral Activation is well-established as
a treatment for depression:

BA by increasing pleasant events for the treatment
of depression (e.g., Lewinsohn, 1974)

BA as the behavioral component of cognitive
therapy treatment for depression (Beck, 1976)

BA as an independently effective intervention for
depression (e.g., Jacobson et al., 1996)

BA as a stand-alone behavioral treatment for Major
Depressive Disorder (Martell, Addis and Jacobson,
2001; Addis & Martell, 2004; Dimidjian et al., 2006; Dobson
et al., 2008)
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
What is Behavioral Activation?
 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

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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)
There is empirical and theoretical
support for applying BA to PTSD:
High rates of co-morbidity of depression and
PTSD
 Conceptual overlap in the factors related to the
maintenance of both depression and PTSD (i.e.
AVOIDANCE)
 Preliminary data support BA for the treatment of
PTSD

BA may be particularly well-suited for the
OIF/OEF Population:

Significant proportion of OIF/OEF veterans
report PTSD and/or depression on their return

There are limitations to current treatments and
models of care
– Little is known about effective early intervention
– Less data to support exposure-based treatments for
veterans
– Stigma against mental health treatment
– Veteran preferences toward present-focused/skillbased interventions
BA may be particularly well-suited for the
OIF/OEF Population:
Majority of Iraq and Afghanistan veterans first
diagnosed with PTSD in non-MH settings (Seal
et al., 2007)
 BA is adaptable to primary care context

–
–
–
–
Simple principles
Straightforward strategies
Evidence for brief versions
May be easily disseminated and combined with
pharmacotherapy
BA Case Conceptualization: Depression
Life
Events
Less
Rewarding
Life
Sad, tired,
worthless,
indifferent,
etc.
Stay home,
stay in bed,
watch TV,
withdraw,
ruminate,
etc.
Loss of friendships,
conflict with supervisor
at work, financial stress,
poor health, etc.
BA Case Conceptualization: PTSD
Trauma
Withdraw from
usual activities
(fear, pain,
functional
limitations)
Increased fear
(sadness,
anger)
Stay home,
stop
socializing,
ruminate,
etc.
Loss of
friendships,
conflict with
supervisor at
work, financial
stress, poor
health, etc.
Preliminary data support BA as a
treatment for PTSD:

Clinical case study: BA improves PTSD and co-morbid
major depression among veteran with chronic PTSD (Mulick
& Naugle, 2004)

Small open trial: BA improves PTSD among veterans with
chronic PTSD (Jakupcak, Roberts, Martell, Mulick, Michael, Reed,
Balsam, Yoshimoto, & McFall, 2006)

Pilot randomized trial: BA improves PTSD among recently
injured trauma survivors, compared to treatment as usual
(Wagner, Zatzick, Ghesquiere, & Jurkovich, 2007)

Small open trial: BA improves PTSD among OIF/OEF
veterans in primary care setting (Jakupcak, Wagner, Paulson,
Varra, & McFall, 2010)
BA for PTSD among Veterans
(Jakupcak, Roberts, Martell, et al. 2006)

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Pre-post open trial
11 outpatients with PTSD, most Vietnam-era
Mean age 51.2 (12.6)
Mean education 15 (2)
10 men
All white
BA delivered in 16 sessions
Most participants had combat-related
trauma and co-morbid conditions:

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
(Jakupcak et al., 2006)
Outcome Measures

Clinician Administered PTSD Scale (CAPS)

The PTSD Checklist (PCL)

Beck Depression Inventory (BDI)

Quality of Life Inventory (QOLI)
(Jakupcak et al., 2006)
Attrition
 Dropped
out (n = 1; travel)
 Completed
15 of 16 sessions; lost to
follow up (n = 1)
(Jakupcak et al., 2006)
Symptom Severity
One-tailed Paired t-test
Pre
Post
t (df)
H’s g
M
(sd)
M
(sd)
CAPS
75
(22)
60
(24)
PCL
52
(13)
48
(20)
2.47 (8) * .58
1.00 (9) .38
BDI
26
(15)
22
(17)
0.86 (9)
.30
-.88 (1.6)
.11
(1.4)
-2.10(8)
-.61
QOLI
*p < .05
(Jakupcak et al., 2006)
BA for PTSD
among Injured Trauma Survivors
(Wagner, Zatzick et al., 2007)
Randomized controlled trial (pilot)
 8 physically injured trauma survivors,
recruited from surgical ward
 Met criteria for PTSD 1-mo post-injury
 Minimized exclusion criteria
 BA delivered in 6 sessions

Sample (N=8)
BA (n=4)
TAU (n=4)
28 (15.4)
39 (16.2)
# male
3
0
# > high school
2
3
# minorities
3
1
# married
1
2
MDD diagnosis
2
2
Age (mean, sd)
(Wagner et al., 2007)
PTSD Outcome (PCL)
62
57
52
47
42
Pre
Post
37
32
27
22
17
BA
TAU
t = 2.85; p < .05; d = 1.19
(Wagner et al., 2007)
Depression Outcome (CESD)
50
45
40
35
30
25
20
15
10
5
0
Pre
Post
BA
TAU
no statistical difference; d = .55
(Wagner et al., 2007)
Physical Functioning (SF-12)
Physical Fx: t = 1.86; p < .11; d = 1.27
(Wagner et al., 2007)
BA for the Treatment of PTSD among
OIF/OEF Veterans
(Jakupcak, Wagner, Paulson, et al., 2010)
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Open trial, pre-post and 3-mo follow-up
Brief BA (8 sessions)
Integrated mental health and primary care
setting
6 veterans completed at least 4 sessions
All Caucasian
Mean age 28 (sd = 5)
4 of 6 had co-morbid MDD
5 of 6 had alcohol abuse
Results: Repeated Measures ANOVAs:
CAPS
F(2,3)=10.66, p<.05, d=1.44
(Jakupcak et al., 2010)
Results: Repeated Measures ANOVAs:
PCL-M
F(2,3)=24.97, p<.01, d=1.87
(Jakupcak et al., 2010)
Results: Repeated Measures ANOVAs:
BDI
F(2,3) = 3.49, ns, d=1.28
(Jakupcak et al., 2010)
Results: Repeated Measures ANOVAs:
Quality of Life
F(2,3)=2.72, ns, d=.62
(Jakupcak et al., 2010)
Summary and Future Directions

BA may have potential as a treatment for PTSD

BA may be an appropriate, first line intervention as part of a
stepped care approach to treating PTSD

BA may be more acceptable to some individuals and easier
to disseminate (e.g., primary care) than other ESTs for
PTSD

Grant-funded for dual-site randomized controlled trial of BA
for recently returning veterans (Wagner, Jakupcak, McFall)

Utilizing aspects of BA in NIMH-funded grant for recently
injured adolescents (Zatzick, PI)
Course of BA
Orient to treatment rationale and
approach
 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
Targets of BA
Avoidance behaviors (inertia, withdrawal,
isolation, ruminating, etc.)
 Routine disruptions, connection between
routine and mood
 Individual environments and relationship
between activity and mood

Individualizing Activation Targets
What are you doing more or less of since
(you were assaulted)?
 What are your goals/values?
 What is the relationship between specific
activities/life contexts/problems and
mood?
 Conduct detailed examination of what is
getting in the way of acting differently or
feeling better.

Functional (Behavioral) Analysis
“A step-by-step assessment of a
problematic behavior or target,
focusing on all aspects and
circumstances of the behavior,
including the antecedents and
consequences.”
Activity Chart: Central Tool in BA
Baseline assessment of activity and
relationship with mood
 Schedule activation
 On-going monitoring of activity and mood
 Evaluate progress

In each box, write the activities you engaged in
during the hour and how you felt. Rate your
feelings on a scale of 1-10, with 1 being the
least intensity of feeling and 10 being the most.
Time
6:00 am
Mood
7:00 am
Mood
8:00 am
Mood
9:00 am
Mood
Day and Date:
Practical Strategies to
Maximize Activation
Plan specific strategy for implementation
(what, when, where, etc.)
 Troubleshoot
 Write it down
 Monitor progress, highlight consequences
 Adopt a scientific/experimental attitude
 Be alert to the “just do it” approach

Maximizing Activation
Take an “outside – in” approach
 Break tasks into manageable components
 Aim for activities that have a high
likelihood of natural reinforcement
 Consider help from significant others
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Blocking Avoidance

Orient patient to avoidance (how it works
in short run and long run)

Identify behaviors that function as
avoidance
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Help patient engage in alternative
behaviors
TRAP/TRAC

T- Trigger
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T-Trigger
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R- Response
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R- Response
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AP- Avoidance
Pattern
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AC- Alternative
Coping
(demands at work)
(depressed
mood/hopelessness)
(stay home in bed,
don’t answer phone)
(demands at work)
(depressed
mood/hoplesness)
(approach behaviors
using graded tasks)
Trigger
Response
AvoidancePattern
Trigger
Response
Alternative
Coping
Routine Regulation

Work with patient to develop regular
routine for basic life activities

Implement, then evaluate
– use activity logs
– use the ACTION strategy
ACTION Strategy

Assess
How will my behavior affect my depression?
Am I avoiding? What are my goals in this
situation?

Choose
I know that activating myself will increase my
chances of improving my life situation and mood.
Therefore, if I choose not to self-activate, I am choosing
to take a break.

Try

Integrate
 Observe
Try the behavior I have chosen.
Integrate any new activity into my daily routine.
Observe the result. Do I feel better or worse?
Did this action allow me to take steps toward improving
my situation?

Now
Now evaluate; OR Never give up.
Targeting Rumination

Rumination can function as avoidance, can
maintain depression

Focus on context and consequences of
rumination, not content
A Focus on the Content of Thinking:
“I was depressed all day yesterday because I was
thinking about how my sister really doesn’t love me.”
* What is the evidence that this thought is accurate?
* What would it mean if it were true?
* Can you think of another way to interpret what your sister
said?
* Why must everyone love you?
A Focus on the Context and
Consequences of Thinking:
“I was depressed all day yesterday because I was
thinking about how my sister really doesn’t love me.”
* When did you start thinking that?
* How long did it last?
* What were you doing while you were thinking that?
* How engaged were you with the activity, context, etc.?
* What were consequences of thinking about that?
Targeting Ruminating

Attention to experience strategies
– notice colors, smells, noises, sights, etc.
– participate in task

Select high engagement activities
Resources

Depression in Context (Martell, Addis, Jacobson,
2001), NY: WW Norton & Company, Inc.

Overcoming Depression One Step at a Time
(Addis & Martell, 2004), Oakland, CA: New
Harbinger, Inc.

Behavioral Activation for Depression: A
Clinician’s Guide (Martell, Dimidjian, Herman-
Dunn & Lewinsohn, 2010), NY: Guilford Press

Behavioral Activation: Distinctive Features
(Kantor, Busch, & Rusch, 2009), Routledge