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
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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
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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)
Course of BA
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Orient to treatment
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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
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Set collaborative agenda
Review homework
Review weekly activities
Troubleshoot problem behaviors
Assign new homework
Ask for feedback
Presentation of Treatment
Rationale
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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
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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
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Rationale for Applying BA to PTSD
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Veteran’s preferences for treatment approaches-
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PTSD and Depression
(e.g, Johnson & Lubin 1997)
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High rates of co-morbidity-(Orsillo et al., 1996)
Common features:
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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
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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
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Anxiety responses generalize over time, such
that any number of situations or triggers induce
a trauma-related response
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Avoidance behaviors perpetuate the learned
stress-response and may inform an individual’s
sense of self-efficacy
Traditional CBT Approaches to
PTSD Treatment
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Exposure based therapies often directly
target re-experiencing, avoidance of
reminders/discussions/thoughts of the
trauma, and hyperarousal symptoms of
PTSD
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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)
Traditional CBT Therapy
Focus: Learn coping skills to
decrease arousal symptoms; revisit
the traumatic event until it no longer
produces arousal; address traumarelated schemas
Symptoms
*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological
Restricted Range of Behavior
Less Rewarding Life
Goals
Decrease symptom severity in order
to increase functioning
Behavioral Activation for PTSD
Conceptualization
Prior Life Functioning
Traumatic Events (s)
Behavioral Activation
Focus: Present centered therapy
Working from the outside-in
Symptoms
*Affective (Mood)
*Avoidance Behaviors
*Cognitive
*Physiological
Restricted Range of Behavior
Less Rewarding Life
Goals
*Broadening behavior
*Defining values & achieving goals
*More fulfilling life
Support for BA as a PTSD
Treatment
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Clinical case studies: BA improves PTSD
and co-morbid Major Depression-Mulick et al.,
2004
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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)
Education M(SD)
Vietnam era
Post Vietnam
51.2 (12.65)
15 (2)
9
2
Trauma Exposure and
Symptom Profiles
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Trauma type
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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
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4 Major Depression/3 dystymia/1 etoh dependence,
remission
7 Chronic pain
7 Actively seeking service connection for PTSD
Outcome Measures
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Clinician Administered PTSD Scale
(CAPS) Blake et al., 1990
The PTSD Checklist (PCL)
Weathers et al., 1993
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Beck Depression Inventory (BDI)
Beck & Steer, 1987
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Quality of Life Inventory (QOLI)
Frisch, 1994
Attrition
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Dropped out (n = 1; travel)
Completed 15 of 16 sessions; lost to
follow up (n = 1)
Symptom Severity
One-tailed Paired t-test
Pre
CAPS
PCL
BDI
QOLI
*p < .05
M
75
52
26
-.88
SD
(22)
(13)
(15)
(1.6)
M
Post
60
48
22
.11
SD
(24)
(20)
(17)
(1.4)
t (df)
Hedge’s g
_____
2.47 (8)* .58
1.00 (9) .38
0.86 (9) .30
-2.10 (8) -.61
Individual Change Scores
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CAPS; reliable change at |9| points
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PCL; reliable change at |5| points
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Six of ten showed improvement; 1 deteriorated
BDI; reliable change at |5| points
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Five of nine of participants showed improvement
four of ten showed improvement; four deteriorated
QOLI; reliable change at |.7| points
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Four of nine showed improvement
Case Example (“non-responder”)
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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
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Values:
Reparation*
 Providing for families (children*)
 Self-Reliance
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Goals:
Resume work
 Provide for family members
 Improve health (related to first two goals)
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Vicious Circle
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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
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Diet
Walking (failures and successes)
Employment seeking
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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
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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
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Will-power or “Nike” model of change
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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
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Discussion, Questions, and
Future Directions
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BA may have potential as a treatment for PTSD and
Chronic Pain symptoms, especially to address quality of life
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BA may be an appropriate, first line intervention as part of a
stepped care approach to treating recently returning
combat veterans
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Initiated open trial of BA for recently returning combat
veterans with PTSD delivered in a Primary Care Clinic
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Planned randomized, multi-site study for returning combat
veterans
Workshop overview
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Basic epidemiology and patient characteristics
A model of integrated care for OIF/OEF veterans
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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
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Fitness for Duty Recommendations
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Confidentiality
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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
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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
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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
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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
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Coping with transition stress
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Improving sleep
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Managing stress
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Dealing with anger
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Reintegrating
Psychological First Aid
http://www.ncptsd.va.gov/pfa/PFA.html
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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%20Bri
efing%20Speaker%20Notes.ppt
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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