A pilot study of behavioral activation for veterans with posttraumatic stress disorder

Journal of Traumatic Stress, Vol. 19, No. 3, June 2006, pp. 387–391 ( C© 2006)

B R I E F R E P O R T

A Pilot Study of Behavioral Activation for VeteransWith Posttraumatic Stress Disorder

Matthew JakupcakSeattle VA Puget Sound Health Care System

Lisa J. RobertsViterion TeleHealthcare, LLC

Christopher MartellUniversity of Washington

Patrick MulickGonzaga University

Scott Michael and Richard ReedSeattle VA Puget Sound Health Care System

Kimberly F. Balsam and Dan YoshimotoUniversity of Washington

Miles McFallSeattle VA Puget Sound Health Care System and University of Washington

A pilot study was conducted to investigate the feasibility and effectiveness of behavioral activation (BA)therapy for veterans with posttraumatic stress disorder (PTSD). Eleven veterans seeking treatment ata Veterans Administration outpatient PTSD clinic were enrolled in the study protocol, consisting of16-weekly individual sessions of BA. Nine veterans completed the protocol, one participant completed15 sessions, and one dropped out after one session. Clinician-rated PTSD symptom severity showedsignificant pre- to posttreatment improvement and was associated with a moderate effect size. A numberof participants also were improved on measures of depression and quality of life, but changes did not reachstatistical significance. Findings suggest that BA is a well-tolerated, potentially beneficial interventionfor veterans with chronic symptoms of PTSD.

Exposure therapy is considered the first-line psychother-

apeutic treatment for PTSD (Ballenger et al., 2001). How-

ever, a number of factors limit application of exposure ther-

apies for some veterans with PTSD, including increased

risk for drop-out (Schnurr et al., 2003), comorbid condi-

This material is based upon work supported by the Office of Academic Affiliations, VA Special MIRECC Fellowship Program in Advanced Psychiatry and Psychology, Department ofVeteran Affairs.

Correspondence concerning this article should be addressed to: Matthew Jakupcak, Seattle VA Hospital, 1660 South Columbian Way, Seattle, WA 98108. E-mail: [email protected].

C© 2006 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20125

tions for which exposure therapy is contraindicated (Litz,

Blake, Gerardie, & Keane, 1990), and Veteran Affairs (VA)

clinicians’ limited use of exposure therapy (Rosen et al.,

2004). Thus, novel treatment approaches for PTSD in

veterans need to be explored.

387

388 Jakupcak et al.

Behavioral activation (BA) therapy may benefit veterans

with PTSD. Behavioral activation originated from rein-

forcement theories and as a component of cognitive ther-

apy for depression (Beck, 1976; Lewinsohn, 1974). Be-

havioral activation has been shown to be an independently

effective intervention for depression (Jacobson et al.,

1996), contributing to its evolution into a stand-alone be-

havioral treatment (see Martell, Addis, & Jacobson, 2001).

Behavioral activation also may be relevant for treating

PTSD, as the avoidant behaviors and functional impair-

ments associated with chronic PTSD are consistent with

those of depression.

Cognitive behavioral models of PTSD suggest that neg-

atively reinforced avoidance and withdrawal behaviors re-

duce negative affect through the avoidance of trauma-

related anxiety cues (e.g., Foa, Steketee, & Rothbaum,

1989). Higher-order conditioning can cause anxiety re-

sponses to generalize to the contemporary environment,

such that patterns of avoidance or withdrawal become glob-

ally applied (see Keane, Zimering, & Cadell, 1985). As a

result, persons with PTSD are likely to remain socially

isolated and avoid potentially rewarding, novel situations.

Patterns of avoidance and withdrawal may explain the as-

sociation between PTSD and impaired quality of life (see

Johnson, Zlotnick, & Zimmeran, 2003) and high rates of

comorbid depression (Orsillo et al., 1996). Because BA en-

courages approach rather than avoidance behaviors, it was

predicted to benefit veterans with PTSD. A pilot study

was conducted to test the feasibility and effectiveness of

BA for veterans with PTSD, with pre to posttreatment

improvements predicted on measures of PTSD, depressive

symptoms, and quality of life.

M E T H O D

Participants

Participants (N = 11) were recruited from the PTSD

Outpatient Clinic of VA Puget Sound Health Care Sys-

tem and screened for inclusion according to the Diagnostic

and Statistical Manual of Mental Disorders, Fourth Edition

(DSM-IV; American Psychiatric Association, 1994) crite-

ria of PTSD as assessed by the Clinician Administered

PTSD Scale (CAPS; Blake et al., 1990). Exclusion cri-

teria included prominent suicidal or homicidal ideation,

psychotic symptoms, or active substance abuse assessed us-

ing the Structured Clinical Interview for DSM-IV Axis-I

Disorders (SCID-I; First, Spitzer, Gibbons, & Williams,

1997).

All participants were White and one veteran was

female. Mean age was 51.2 years (SD = 12.7). Nine vet-

erans identified their primary trauma as related to service

in Vietnam, with all but one indicating combat-exposure.

The female participant identified her primary trauma as

sexual assault and one veteran’s trauma occurred during

Bosnian peacekeeping duties. Seven veterans met crite-

ria for major depressive disorder and one met criteria for

dysthymia.

Procedure

Therapists and raters. Clinical team members included

three doctoral level psychologists and two predoctoral psy-

chology interns. The same rater, a member of the research

team other than the patient’s therapist, performed initial

screenings, baseline assessments, and posttreatment assess-

ments. At posttreatment assessment, raters were kept blind

to baseline scores. Christopher Martell, who holds a PhD,

trained and supervised the therapists. All sessions were

audiotaped; Dr. Martell who provided weekly group su-

pervision to promote treatment integrity reviewed them

weekly.

Treatment. The BA intervention consisted of a 16-session

manualized individual therapy, prescribing semistructured

activities to help participants make contact with natural

reinforcers in their environment. Therapists worked col-

laboratively with clients to identify avoidance behaviors,

set goals, and practice meaningful activities. Veterans com-

pleted daily activity and mood charts and therapists assisted

the clients identify anxiety-triggers, emotional and behav-

ioral responses, and subsequent consequences. Although

not formally assessed, therapists noted good compliance

with therapeutic assignments.

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Behavioral Activation for PTSD 389

Behavioral activation encourages approach rather than

avoidance behaviors, so assignments may have involved ha-

bituation to discomfort or anxiety associated with adopt-

ing new behaviors (e.g., exercise). However, veterans were

not explicitly required to confront traumatic memories.

Suppose a client reported that he had regularly gone hunt-

ing for recreation prior to his combat experiences, but

no longer enjoys it because firearms remind him of his

trauma. The BA therapist might help examine what was

enjoyable about hunting (e.g., spending time in nature)

and suggest alternative behaviors (e.g., hiking or fishing)

that bring about rewards previously associated with hunt-

ing. The goal of BA is not to habituate to traumatic cues

or memories but rather to re-engage in meaningful activi-

ties, perhaps overcoming contemporary sources of anxiety

(e.g., going to new places) reinstate feelings of reward and

pleasure.

Measures

The primary outcome measure was the CAPS (Blake et al.,

1990), a semistructured interview that assesses the fre-

quency and intensity of each of the PTSD symptoms and

provides a continuous measure of symptom severity. The

PTSD Check List (PCL; Weathers et al., 1993) was used as

a self-report measure of the PTSD symptom severity. De-

pression was assessed using the Beck Depression Inventory

(BDI; Beck & Steer, 1987). Quality of life was assessed

Table 1. Treatment Outcomes for Behavioral Activation Therapy for Posttraumatic Stress Disorder(PTSD)

Baseline PostReliable

Outcome M (SD) M (SD) t(df ) Hedge’s g changea

CAPS 74.66 (22.11) 60.44 (24.03) 2.47 (8)* .58 5 improvedPCL 52.33 (12.58) 47.80 (18.12) 1.70 (9) .38 6 improved

1 deterioratedBDI 27.90 (14.56) 22.90 (16.33) 1.06 (9) .30 4 improved

4 deterioratedQOLI −0.88 (1.64) 0.11 (1.39) −2.10 (8)∗∗ −.61 4 improved

Note. CAPS = Clinician Administered PTSD Scale; PCL = PTSD Checklist; BDI = Beck Depression Inventory; QOLI = Quality ofLife Inventory.aReliable change criteria where CAPS ±9, PCL ±5, BDI ±5, QOLI ±0.69 points.∗ p < .05. ∗∗ p = .07.

pre- and posttreatment using the Quality of Life Inventory

(QOLI; Frisch, 1994).

R E S U L T S

Retention

One veteran discontinued treatment after the initial session

citing transportation difficulties. One veteran completed

15 of the 16 sessions but did not complete CAPS or QOLI

postassessments; as this was considered an adequate dose

of treatment, the veteran’s PCL and BDI scores at week

15 were used in lieu of the missing posttreatment assess-

ment scores on these measures.

Treatment Response

Table 1 presents the results of two-tailed, paired sample

t tests of outcome measures and individuals’ responses to

treatment. Hedge’s g was calculated to represent effect size

for a repeated measures design and interpreted according

to Cohen’s (1998) definitions. Table 1 reports the criteria

for reliable change derived from the formula detailed in

previous research (Foa et al., 2002).

There was a statistically significant reduction in PTSD

symptom severity, with five veterans demonstrating reliable

symptom reductions on the CAPS that ranged from 12 to

44 points (M = 21.6). Four of these five veterans met


390 Jakupcak et al.

DSM-IV criteria for PTSD at posttreatment. Four of nine

veterans did not demonstrate reliable change on the CAPS.

The decrease of PCL scores from pretreatment to posttreat-

ment was associated with a small-to-medium effect size. Six

of 10 veterans demonstrated symptom reduction on the

PCL and one demonstrated an increase in symptom sever-

ity. Change of BDI depression scores was not significant.

Four veterans reported a decrease in symptom severity, and

four veterans reported an increase in depression severity.

Two veterans demonstrated no change. There was a trend

toward significant improvement on the QOLI, with four

of the nine veterans demonstrating reliable improvement.

D I S C U S S I O N

There was a statistically significant reduction of PTSD

severity scores on the CAPS, with more than half of the

veterans demonstrating reliable improvement. Individual

change measured by the CAPS was variable and the over-

all effect size for group pre to postchange was modest.

Change in PCL scores was not statistically significant for

the sample; however, more than half of the veterans indi-

vidually demonstrated reliable improvement. Depression

scores showed no significant change. Four veterans im-

proved over the course of treatment and four veterans re-

ported a worsening of depression symptom severity. Three

of the four veterans with increased depression showed no

change in PTSD symptoms on the CAPS or PCL, whereas

the fourth veteran demonstrated a decrease of 20 points on

the CAPS, a 4-point reduction on the PCL, and reliable

improvement in quality of life, suggesting an overall pat-

tern of improvement. There was a trend toward statistically

significant improvement in quality of life scores with four

of nine veterans reporting reliable improvement. All veter-

ans tolerated enrollment and screening procedures and no

veteran reported negative reactions to the BA therapy.

The deterioration of depression in four veterans was sur-

prising, as BA was developed for the treatment of depres-

sion. It is possible that the nonresponders became more

depressed as a result of an unsuccessful trial of therapy

for PTSD. Alternatively, these veterans may have become

more depressed because of some unmeasured factor (e.g.,

increase in current psychosocial stressors or a worsening of

physical or medical conditions).

There were a number of limitations of this study. Mem-

bers of the research team who were aware of the goals of

the study performed assessments. Although raters were not

provided with their original baseline CAPS scores at post-

treatment assessment, knowledge of the study’s objectives

may have led to exaggerated ratings improvement. It is im-

portant to note that improvements observed in the veterans

cannot be determined to be uniquely attributable to BA, as

there was no randomization to a comparison group and no

efforts to prevent medication changes during enrollment

in the study. Finally, these findings may not generalize to

other populations (e.g., civilians with PTSD).

Despite these limitations, the current results suggest

that further investigation of BA as an intervention for

PTSD is warranted. Behavioral activation strategies are

easy to learn, intuitive, and readily embraced by both pa-

tients and clinicians. A number of the veterans with com-

plex psychiatric profiles and chronic symptoms of PTSD

responded positively to BA strategies. Behavioral activa-

tion may be particularly useful for veterans who cannot

tolerate exposure therapy or who have pronounced avoid-

ance symptoms. Subsequent research efforts should include

randomized, controlled outcome methodology with long-

term follow-up assessment utilizing diverse populations to

examine more closely BA’s effectiveness as an intervention

for PTSD.

R E F E R E N C E S

American Psychiatric Association. (1994). Diagnostic and statis-tical manual of mental disorders (4th ed.). Washington, DC:Author.

Ballenger, J. C., Davidson, J. R., Lecrubier, Y., Nutt, D. J., Foa,E. B., Kessler, R. C., et al. (2001). Consensus statement onposttraumatic stress disorder from the International ConsensusGroup on Anxiety and Depression. Journal of Clinical Psychiatry,61, 60–66.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders.New York: New American Library.

Beck, A. T. & Steer, R. A. (1987). Beck Depression Inventory man-ual. New York: Harcourt Brace.


Behavioral Activation for PTSD 391

Blake, D., Weathers, F., Nagy, L., Kaloupek, D., Klauminzer, G.,Charney, D., et al. (1990). Clinician-Administered PTSD Scale(CAPS). A clinician’s rating scale for assessing current and lifetimePTSD: The CAPS-1. Behavior Therapist, 13, 187–188.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences(2nd ed). Hillsdale, NJ: Erlbaum.

First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W.(1997). Structured Clinical Interview for DSM-IV Axis-I Dis-orders (SCID-I), Clinical Version. Washington, DC: AmericanPsychiatric Press.

Foa, E. B., Steketee, G., & Rothbaum, B. O. (1989). Behavioral/cognitive conceptualizations of post-traumatic stress disorder.Behavior Therapy, 20, 155–176.

Foa, E. B., Zoellner, L. A., Feeny, N. C., Hembree, E. A., & Alvaraez-Conrad, J. (2002). Does imaginal exposure exacerbate PTSDsymptoms? Journal of Consulting and Clinical Psychology, 70,1022–1028.

Frisch, M. B. (1994). Manual and treatment guide for the Quality ofLife Inventory. Minneapolis, MN: National Computer Systems,Inc.

Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner,K., Gollan, J. K., et al. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting andClinical Psychology, 64, 295–404.

Johnson, D. M., Zlotnick, C., & Zimmeran, M. (2003). The clinicalrelevance of a partial remission specifier. Journal of TraumaticStress, 16, 515–518.

Keane, T. M., Zimering, R. T., & Cadell, J. M. (1985). A behavioralformulation of posttraumatic stress disorder in Vietnam veterans.Behavior Therapist, 8, 9–12.

Lewinsohn, P. M. (1974). A behavioral approach to depression. InR. M. Friedman & M.M. Katz (Eds.), Long-term treatment ofdepression (pp. 197–228). New York: Wiley.

Litz, B. T., Blake, D. D., Gerardie, R. G., & Keane, T. M. (1990).Decision-making guidelines for the use of direct therapeutic ex-posure in the treatment of post-traumatic stress disorder. TheBehavior Therapist, 13, 91–93.

Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depressionin context: Strategies for guided action. New York: W & WCompany, Inc.

Orsillo, S. M., Weathers, F. W., Litz, B. T., Steinberg, H. R., Huska,J. A., & Keane, T. M. (1996). Current and lifetime psychiatricdisorders among veterans’ war-zone related posttraumaticstress disorder. Journal of Nervous and Mental Disorders, 184,307–313.

Rosen, C. S., Chow, H. C., Finney, J. F., Greenbaum, M. A., Moos,R. H., Sheikh, J. I., et al. (2004). VA practice patterns andpractice guidelines for treating posttraumatic stress disorder.Journal of Traumatic Stress, 17, 213–222.

Schnurr, P. P., Friedman, M. J., Foy, D. W., Shea, M. T.,Hsieh, F. Y., Lavori, P. W., et al. (2003). Randomized trialof trauma-focused group therapy for posttraumatic stressdisorder: Results from a Department of Veteran Affairs co-operative study. Archives of General Psychiatry, 60, 481–489.

Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A.,& Keane, T. M. (1993, October). The PTSD Checklist(PCL): Reliability, validity, and diagnostic utility. Paperpresented at the 9th Annual Meeting of the Interna-tional Society for Traumatic Stress Studies, San Antonio,TX.


Documents

A pilot study of behavioral activation for veterans with posttraumatic stress disorder