The International Journal of Behavioral Consultation and Therapy ©2011, All rights reserved.

2011, Vol. 7, No. 1, 23–31 ISSN: 1555 - 7855

Contextual Behavior Therapies in the Treatment of PTSD:

A Review
Patrick S. Mulick
Department of Psychology
Gonzaga University

Sara J. Landes Jonathan W. Kanter

Department of Psychology Department of Psychology
University of Wisconsin-Milwaukee University of Wisconsin-Milwaukee

Empirical evidence supports cognitive -behavioral interventions for the treatment Posttrau-
matic Stress Disorder (PTSD), with exposure therapy typically being the most frequently uti-
lized. While the success of exposure treatments is well established there are factors which
may hinder their use in “real-world” settings (e.g., poor treatment compliance, high drop-out
rates, aversive nature of the procedures). These limitations indicate that the field of psychol-
ogy needs to continue to search for effective and palatable PTSD interventions. Contextual
behavior therapies, such as Acceptance and Commitment Therapy, Behavioral Activation, Di-
alectical Behavior Therapy, and Functional Analytic Psychotherapy, may be these alternatives.
This paper reviews the theoretical rationale and available empirical literature related to the use
of these treatments with trauma populations.
Keywords: Post-traumatic Stress Disorder, Contextual behavior therapies, Acceptance and
Commitment Therapy, Behavioral Activation, Dialectical Behavior Therapy, Functional An-
alytic Psychotherapy.

It has long been recognized that traumatic events can pro- sive thoughts), (2) avoidance symptoms (e.g., avoidance of
duce psychiatric symptoms1 in individuals who were previ- the reminders of the trauma, avoidance of thoughts about
ously well adjusted; however, the overriding notion was that the trauma, emotional numbing), and (3) increased arousal
the stress-induced symptoms were transient (Wilson, 1994). (e.g., heightened startle response, insomnia). The diagnosis
The Diagnostic and Statistical Manual for Mental Disorders of PTSD is satisfied if the symptoms persist for a minimum
(DSM; American Psychiatric Association, 1952) contained of 4 weeks.
the diagnosis of “gross stress reaction” and DSM-II (APA, Exposure to the types of traumatic events that can lead to
1968) contained the diagnosis of “transient situational dis- psychiatric difficulties is extremely common. Nearly 60% of
turbance.” As the DSM-II diagnostic label indicates, both men and 50% of women experience a traumatic event at some
versions assumed that trauma- induced symptom-responses point during their lifetime (Resick, 2001; Schnurr, Friedman,
were temporary and would dissipate, and any symptoms that & Bernardy, 2002). There is great variation in the prevalence
remained were characteristic of a separate psychological dis- rates of PTSD in the general population. Kessler, Sonnega,
turbance (McNally, 1999). The return of Vietnam veter- Bromet, Hughes, and Nelson (1995) found that among the
ans and increasing awareness of their symptoms generated general population, estimates of lifetime PTSD are 5% for
a debate that helped change the professional perception of men and 10% for women. Among traumatized individuals,
psychological response to traumatic events (McNally, 1999). lifetime prevalence rates increase to 8% in men and 20%
The APA DSM-III Task Force explored cases of individu- in women (Kessler et al.). It is difficult to gather a very
als who had experienced incidents of war, rape, and nat- clear picture of the frequency of this disorder by looking at
ural disasters. They concluded that these types of events the general population because the likelihood of developing
could give rise to a common constellation of symptoms and PTSD varies with the type of trauma experienced. Those
a unique psychological syndrome. Based on their recom- that occur with the most frequency (motor vehicle accident,
mendation, DSM-III (APA, 1980) was the first edition to witnessing someone being injured/killed, and natural disas-
include the diagnostic label of Posttraumatic Stress Disor- ters) tend to have lower PTSD prevalence rates than those
der (PTSD). The diagnosis has remained throughout the re- less frequently experienced (combat, child abuse, and sexual
visions of DSM-III-R (APA, 1987), DSM-IV (APA, 1994),
and DSM-IV-TR (APA, 2000) with slight modifications to 1
While we use the nomenclature of DSM in this paper, when we
the original defined criteria. The current criteria include speak of “symptoms” of a disorder we are not speaking of signs
symptoms from three defined symptom clusters: (1) recur- of some underlying problem other than the behavior itself. The
rent re-experiencing of the trauma (e.g., nightmares, intru- symptoms are behaviors, and the disorder represents a commonly-
occurring set of behaviors.

23
24 MULICK, LANDES, & KANTER

assault), with sexual assault being the most likely event to distinguishing these views it is important to explore their
result in PTSD (Resick). Kessler and colleagues found that root metaphors (their comprehensive way of representing
the vast majority of men (88%) and women (79%) who met things in the world). The root metaphor for mechanism is
criteria for PTSD also met criteria for at least one other DSM the machine. The mechanistic perspective views the world
diagnosis. Substance abuse and depression are the most fre- as individual parts working together to make up the whole.
quent, with co-morbidity rates consistently exceeding 50% This mechanistic view is held by first generation behavioral
(Gold, 2004; Kessler et al.; McFarlane & de Girolamo, 1996; theories, cognitive theories, and biological theories of psy-
Resick). chopathology. If there are problems, the mechanist locates
Modern behavioral treatment of PTSD focuses on expo- the part that is broken (i.e., neurotransmitter imbalance, de-
sure, although relaxation techniques are often also applied. pressive schema, poor social skills) and repairs it, thus re-
Exposure is based on the simple notion that anxiety subsides turning the system to normal. In contrast, the root metaphor
through a process of habituation after exposure to the feared of contextualism is the “ongoing act in context” (Dougher
stimulus. Applied to PTSD, the exposure usually involves & Hayes). Action is integrated within its context and set-
imaginal re-presentation of the traumatic events and blocking ting rather than separated from it. Simply put, contextual
escape (through dissociation or distraction). While extensive interventions focus on the function of behavior, rather than
research supports the use of exposure therapy in the treat- the form. For example, the action of running can have very
ment of PTSD (Rothbaum, Meadows, Resick, & Foy, 2000), different meaning depending on the context (e.g., exercising,
exposure interventions appear to be most effective in treating late for work, being chased by a rabid dog). A similar anal-
re-experiencing and hyperarousal symptomatology, with less ysis can be constructed by looking at the avoidance behavior
impact on the avoidance symptoms (Blake & Sonnenberg, frequently seen in individuals who suffer from PTSD.
1998). As stated earlier, avoidance symptoms are one of the core
Despite this strong empirical evidence, practitioners in diagnostic, and most difficult to treat, features of PTSD. In-
“real-world” settings do not appear to utilize exposure inter- dividuals will go to great lengths to avoid people, places,
ventions with great frequency (Becker, Zayfert, & Anderson, objects, thoughts, and feelings associated with the traumatic
2004; Cook, Schnurr, & Foa, 2004). There is debate as to event. Within the contextualist approach it is not the anx-
why these therapies are not implemented at a higher rate. iety, sadness, and/or aversive thoughts and memories that
Commonly suggested barriers include: high rates of treat- are pathological, rather the pathology lies in the avoid-
ment non- compliance (Foa, Rothbaum, Riggs, & Murdock, ance strategies (Follette, 1994; Pistorello, Follette, & Hayes,
1991; Tarrier et al., 1999; Vaughan & Tarrier, 1992); high 2000; Walser & Hayes, 1998). As a result, while exposure-
drop-out rates (Schnurr, 2001); the observation that some pa- based interventions attempt to eliminate aversive emotions
tients fail to enroll because they are intimidated or may find (i.e., repair the broken part), contextual behavior therapies
the treatment too aversive (Rothbaum et al., 2000; Scott & are focused on assisting the client to explore the function of
Stradling, 1997); limited empirical work to guide clinicians their avoidance behaviors (i.e., action in context).
on how to treat PTSD when it co- occurs with another Axis In this paper, we provide brief theoretical and empirical
I disorder (Cook et al.; Shalev, Friedman, Foa, & Keane, reviews of ACT, BA, DBT, and FAP. Due to space limitation,
2000); and lack of comfort with or knowledge of the inter- we are not able to supply comprehensive theoretical descrip-
vention by clinicians (Becker et al.). While these difficulties tions of each intervention, but foundational principles and
do not negate the value of exposure therapy, they do sug- rationale for their use with the PTSD population will be pre-
gest that the field needs to continue to search for effective sented. Given that the field is still in its infancy in exploring
PTSD interventions, particularly those that target avoidance these therapeutic approaches in the treatment of PTSD, there
behaviors, which may be more palatable to both clinicians is limited empirical literature available that examines their
and clients. effectiveness. The majority of literature available is in the
It is possible that contemporary behavior therapies might form of case studies or conference presentations.
provide effective alternatives to these exposure-based inter-
ventions. In fact, the last decade has witnessed the emer-
gence of a “third wave” of behavior therapies (Dougher & ACCEPTANCE AND C OMMITMENT T HERAPY (ACT)
Hayes, 2000; Hayes, 2004; Hayes, Masuda, Bissett, Luoma,
& Guerrero, 2004). This current movement includes thera- Acceptance and Commitment Therapy is a comprehensive
pies such as Acceptance and Commitment Therapy (ACT; intervention that has been implemented in various modalities
Hayes, Strosahl, & Wilson, 1999), Behavioral Activation and with a variety of psychiatric populations (Hayes et al.,
(BA; Martell, Addis, & Jacobson, 2001), Dialectical Behav- 2004; Hayes et al., 1999). The philosophical grounding of
ior Therapy (DBT; Linehan, 1993), and Functional Analytic ACT is in functional contexualism (Hayes, 1993) and Re-
Psychotherapy (FAP; Kohlenberg & Tsai, 1991). lational Frame Theory (RFT; see Hayes, Barnes-Holmes, &
These “third wave” therapies share a contextualistic world Roche, 2001 for RFT review). At its essence, ACT targets
view. Pepper (1942) described two possible world hy- experiential avoidance: An unwillingness to remain in con-
potheses or world views—contextualism and mechanism tact with particular private experiences coupled with attempts
—which have largely dominated the field of behavioral ther- to escape or avoid these experiences (Hayes, 2004; Hayes,
apy (Dougher & Hayes, 2000; Martell et al. , 2001). In Wilson, Gifford, Follette, & Strosahl, 1996). These authors
 CONTEXTUAL BEHAVIOR THERAPIES IN THE TREATMENT OF PTSD 25
suggest that experiential avoidance often does not work, as who was suffering from co-morbid polysubstance abuse and
the events (thoughts and feelings) targeted for avoidance of- PTSD (childhood sexual abuse). At the pre-treatment assess-
ten are respondent or classically conditioned. In addition, ment the client demonstrated a moderate level of general psy-
experiential avoidance may work in the short term (reduc- chological distress, depressive symptomatology, experiential
tion/elimination of unwanted private event) but lead para- avoidance, and thought suppression. Despite experiencing
doxically to a subsequent increase in the events targeted for significant life stressors (death of her mother and an unex-
avoidance and produce chronic aversive private events in pected pregnancy) over the 18 month course of treatment, the
the long term (e.g., heightened re-experiencing symptoms, post-treatment assessment demonstrated improvement across
numbing, dissociation). When experiential avoidance does all measures to below clinically significant levels.
work in the short term, a generalized avoidance repertoire
may be reinforced which may result in poor problem solving
and restricted change efforts when needed in the future. B EHAVIORAL ACTIVATION (BA)
While research on experiential avoidance as a precise
technical process is still in its infancy (Hayes et al., 2004), For the purpose of exploring the mechanism of action of
Hayes and colleagues (1996) reviewed several converging Cognitive Therapy for depression (CT; Beck, Rush, Shaw, &
lines of experimental evidence (e.g., thought suppression, Emery, 1979), Jacobson and colleagues (1996) conducted a
avoidant and “emotion-focused” coping styles) that implicate component analysis of the intervention. Their research pro-
experiential avoidance as functionally important to many vided evidence that BA, the behavioral component of CT,
clinical syndromes, including PTSD. A key feature of this was as effective at reducing depressive symptomatology as
description is that it highlights environmental factors neces- the full CT intervention, and results were maintained over
sary for the acquisition of a generalized experiential avoid- a two-year follow up (Gortner, Gollan, Dobson, & Jacobson,
ance repertoire. In other words, while private events may be 1998). These results called into question the need for explicit
naturally aversive, and thus avoidance of private events may cognitive interventions when treating depression and led to a
be reinforcin g in the short term without additional train- number of studies that have more thoroughly examined the
ing, the theory of experiential avoidance largely suggests effectiveness of BA as a stand-alone treatment. In an effort
that most clinically-relevant private events are not inevitably to replicate and extend the original findings, Dimidjian and
aversive but only become so through complex language and colleagues (2004) conducted a study comparing BA (Martell
socialization processes. et al., 2001), CT (Beck et al. , 1979), paroxetine (Paxil)
In ACT, many PTSD symptoms are seen as related to with clinical management (Fawcett, Epstein, Fiester, Elkin,
an experiential avoidance response class, resulting not only & Autry, 1987), and pill placebo in the treatment of depres-
avoidance of environmental stimuli associated with the trau- sion. The results indicated that BA and paroxetine were com-
matic event, but avoidance of thoughts, memories, and other parable in their effectiveness and that both outperformed CT
verbal stimuli that obtain aversive functions by being in re- and pill placebo. Additionally, Porter, Spates, and Smitham
lational networks with such environmental stimuli. ACT (2004), explored the effectiveness of BA in a group modality
also highlights how efforts to avoid these stimuli may in fact (BAGT) on a chronically depressed, difficult -to-treat pub-
backfire, leading to uncontrollable, intrusive thoughts, night- lic mental health population. The researchers demonstrated
mares, and hyperarousal about future sources of related aver- that those individuals who received BAGT (N = 26) demon-
sive stimulation. ACT techniques directly target these pro- strated a statistically and clinically significant reduction in
cesses. First, clients are helped to contact the fact that their their symptoms of depression from pre-treatment to 3-month
efforts to avoid aversive private experiences may be making follow-up.
the situation worse. Then, defusion, mindfulness, and accep- As the clinical utility of BA has emerged, the authors of
tance exercises teach clients alternate response options when this early research have clarif ied the theoretical underpin-
faced with aversive private events. Finally, clients are taught nings of the intervention (Jacobson, Martell, & Dimidjian,
to focus on personally-chosen values and guided to make and 2001; Martell et al. , 2001) by incorporating Ferster’s (1973)
keep commitments to behavior change in the service of those functional analysis of depression. In this theory it is an as-
values rather than in the service of experiential avoidance. sessment of the function of the behavior, rather than the form,
In doing so, ACT moves away from the symptom reduction that is important in facilitating clinical change. This view
goal underlining standard exposure-based interventions. can be differentiated from the work of Lewinsohn (1975),
Two published case studies address the use of ACT with who suggested an increase in pleasant events was indicated
individuals suffering from PTSD symptomatology. Orsillo in the treatment of depression. Thus, the modern theory of
and Batten (2005) comprehensively outlined the specific BA demands that the clinician and client perform a functional
therapeutic aspects of ACT in treating a 51-year-old Viet- analysis of the client’s behavior and develop a treatment plan
nam War combat veteran. While the authors did not report focused on address ing the client’s avoidance behavior in an
specific data on standardized psychological measures, they attempt to assist him or her to engage in more active behav-
did provide details of each stage of treatment, the specific iors. An increase in active behaviors enables the client to
interventions used, and positive clinical results seen in the come into contact with more reinforcers in his or her envi-
client over the course of treatment. Batten and Hayes (in ronment. Behavioral Activation holds that it is unrealistic to
press) examined the use of ACT with a 19-year-old female assume that an individual is able to go through life engaging
26 MULICK, LANDES, & KANTER

in only pleasurable activities. As told to clients, it is not a the baseline and intervention phases of the study. At the post-
matter of doing things when you feel like it. Rather, it is treatment assessment sessions, self-report and observer rated
engaging in activity because the behavior will help you to data indicated that two participants no long met criteria for
accomplish goals you have set (Martell et al. ). The client either MDD or PTSD and an additional participant no longer
must be taught to effectively and consistently engage with met criteria for MDD. Again, it was specifically noted that
his or her life. all participants rated their satisfaction with BA as very high,
Behavioral Activation’s focus on modifying avoidance providing further evidence of the palatability of this particu-
strategies suggested it as an effective treatment for PTSD. lar intervention.
As stated above, avoidance is a key symptom of PTSD and Jakupack and colleagues (2004) reported the results of a
individuals with PTSD have become hypervigilant in assess- pilot study examining a 16-week BA intervention in the treat-
ing their environment to locate any indication of trauma re- ment of PTSD in a veteran population. Nine of the original
lated cues, including their emotional responses. Perceived 11 participants completed all assessments and the treatment
risk leads to avoidance responses which are negatively rein- phase of the study. Self-report and observer rated measures
forced, even if the risk was never actually present. Behav- of depression, PTSD, and quality-of-life were administered
ioral Activation targets these avoidance responses and assists pre- and post-treatment. Additionally, depression and PTSD
clients in engaging in behaviors that are intended to facili- self-report measures were completed by the participants be-
tate accomplishing their goals, rather than feeling good. It fore their weekly therapy sessions. Results demonstrated sta-
is a subtle form of exposure because individuals are asked to tistically significant improvement in PTSD symptomatolo gy
engage in behaviors that may have become associated with and quality-of-life scores. In aggregate, there was not a sta-
the traumatic experience. However, they are not asked to tistically significant change in self-reported scores of depres-
engage in these behaviors for the explicit purpose of expo- sion. However, the authors indicated that this may be a result
sure, rather it is simply an attempt to remain active with their of numerous participants having pre-treatment scores of de-
environment. pression in the mild range. When examined as a whole, the
Three studies have been completed that examine the ef- majority of participants had a reduction of BDI scores of 7 or
fectiveness of BA in treating PTSD alone or the co-morbid more points from pre- to post-treatment assessment. Finally,
condition of PTSD and Major Depressive Disorder (C-P/D). all veterans tolerated BA very well and indicated that it was a
Mulick and Naugle (2004) completed a case study that ex- useful intervention that affected numerous areas of their lives
amined BA in treating a 37-year-old, married, Caucasian (e.g., health related behaviors).
male who had experienced numerous traumatic experiences
(i.e., attempts on his life, investigations and witnessing acci-
dents involving loss of life) during the course of his careers D IALECTICAL B EHAVIOR T HERAPY (DBT)
as a police officer and a member of the military. He met
DSM-IV criteria for both PTSD and MDD. The client had The correlation between a diagnosis of Borderline Personal-
been through numerous other modalities of treatment in the ity Disorder (BPD) and a history of trauma is clear. Golier
past, including group and pharmaceutical interventions. The and colleagues (2003) found that outpatient subjects with
BA treatment consisted of 11 sessions, which occurred on BPD had significantly higher rates of childhood or adoles-
a weekly basis. Self-report data were gathered at each ses- cent physical abuse than those without a diagnosis of BPD
sion and again at mid-point between each session. At post- but with other personality disorder diagnoses (52.8% versus
treatment assessment, self-report and observer rated data in- 34.4%) and were twice as likely to develop PTSD. Herman,
dicated that the client no longer met criteria for either PTSD Perry and van der Kolk (1989) found a strong association
or MDD. Results at 1-month follow-up suggested that the between a BPD diagnosis and history of childhood abuse.
therapeutic gains were not only maintained, but that the client Significantly more subjects with a BPD diagnosis (81%)
continued to improve. The authors made particular note of had trauma histories including physical abuse (71%), sex-
the client’s high satisfaction with BA. They indicated that ual abuse (68%), and witnessing serious domestic violence
this aspect should not go unnoticed given the perceived aver- (62%). A number of other researchers have found similar
sive nature exposure therapy. results, including evidence that those with a BPD diagnosis
Mulick and Naugle (2002) further investigated the effi- report more types of childhood trauma (Battle, Shea, John-
cacy of 10-weeks of BA in the treatment of C-P/D in four son, Yen, Zlotnick, & Zanarini, 2004; Ogata, Silk, Goodrich,
adults using a nonconcurrent multiple baseline across par- Lohr, Westen, & Hill, 1990; Sansone, Songer, & Miller,
ticipants design. Again, all participants met DSM-IV crite- 2005; Zanarini, Gunderson, Marino, Schwartz, & Franken-
ria for both MDD and PTSD at the pre-treatment assessment burg, 1989).
session. The participants had experienced various traumatic Dialectical Behavior Therapy (Linehan, 1993) is a be-
experiences: two women (21- and 28-years-old) had been havior therapy originally designed for treating parasuicidal
sexually assaulted, one male (56-years-old) was a Vietnam behavior in clients with a diagnosis of BPD. DBT uses
War combat veteran, and one male (47-years-old) had ex- exposure-based procedures “informally” throughout treat-
perienced physical and sexual abuse between the ages of 5 ment to expose clients to aversive emotional states. However,
to 21. Self-report data were gathered at each session and DBT posits that PTSD symptoms in BPD clients should be
again at mid-point between each session for the duration of targeted in a focused manner only after clients are stable and
 CONTEXTUAL BEHAVIOR THERAPIES IN THE TREATMENT OF PTSD 27
life-threatening behaviors such as suicide attempts and self - peutic relationship described by Kohlenberg and Tsai (1991).
mutilation are under control. In DBT, standard exposure pro- Underlying FAP is the key behavior analytic position that it
cedures are used and somewhat modified. Modifications are is easier to deal with actual behavior as it occurs in session
made to target emotions such as guilt, shame, and anger. In as opposed to verbal descriptions of the behavior (Kanter,
addition, DBT offers several suggestions for how to engage Callaghan, Landes, Busch, & Dee, 2004). FAP identifies
clients in exposure treatment, including orienting clients to in-session occurrences of relevant daily life behaviors and
how the exposure treatment will help them reach their ther- labels them Clinically-Relevant Behaviors (CRBs), and fur-
apeutic goals, obtaining client commitment to do the expo- ther specifies both client problems (CRB1s) and improve-
sure before beginning treatment, and validating the extreme ments (CRB2s) that occur in session. The therapeutic task
difficulty of the aversive experiences elicited by exposure. in FAP is contingent responding to naturally reinforce and
Wagner and Linehan (1998) proposed a behavioral ap- increase the frequency of CRB2s while ignoring, punishing,
proach using select strategies and skills from DBT for treat- or otherwise decreasing the frequency of CRB1s (Follette,
ing dissociative behavior, which has been reported in numer- Naugle, & Callaghan, 1996). As described below, in the case
ous studies of trauma populations (e.g., Chu & Dill, 1990; of PTSD the task may also include elicitation of respondent
Zlotnick, Begin, Shea, Pearlstein, Simpson, & Costello, CRB1s and habituation and extinction of them through non-
1994). Dissociative behavior can be viewed as avoidance reinforced exposure.
of aversive internal or external stimuli. First, a behavioral The in-session focus in FAP naturally leads to an empha-
analysis of the dissociative behavior is conducted by getting sis on interpersonal problems, as the therapeutic relationship
a description of the behavior and then conducting a chain is a powerful stimulus that elicits and evokes interpersonal
analysis of the sequence of events before and after the behav- avoidance, problems with intimacy, conflict, fear, anger, in-
ior. The goal is to find the factors related to the behavior and appropriate sexual feelings and other interpersonal difficul-
identify places for behavior change. Based on the analysis, ties. Thus, FAP may be useful whenever a client presents
the therapist can use strategies such as emotion regulation with significant interpersonal problems and there is potential
skills, cognitive restructuring, or exposure to aversive emo- for these problems to occur in the context of the therapeutic
tions. The first target in the treatment of dissociative behavior relationship. In the case of PTSD, FAP may be useful when
is to decrease the availability of cues to traumatic experiences the trauma is human- made (e.g., rape, violence) vs. natu-
which can elicit dissociative behavior. This includes avoid- ral (e.g., natural disasters), because if the traumatic stimulus
ing discussion of trauma until Stage 2 of DBT treatment, itself is human and interpersonal, then the therapeutic rela-
avoiding current traumatic environments, or using distress tionship may elicit conditioned responses similar to those as-
tolerance skills. The second target is to regulate emotional sociated with the original trauma and evoke avoidance and
responses to traumatic cues and aversive emotions. Dialecti- dissociative responses in turn. In fact, FAP may be relevant
cal Behavior Therapy accomplishes this goal through teach- to many cases of PTSD, as research indicates that the likeli-
ing mindfulness and emotion regulation skills and exposure hood of developing a PTSD response to a trauma is greater
to present emotions and traumatic experiences. Finally, the for human- related than natural traumas (Breslau, Kessler,
third target is to change the value of the cue linked to trau- Chilcoat, Schultz, Davis, & Andreski, 1998).
matic experiences. Formal exposure procedures used in DBT Kohlenberg and Tsai (1998) described two types of
Stage 2 treatment are used to change these associations. PTSD—circumscribed and elaborated. Circumscribed PTSD
While a number of studies examining DBT outcomes in (CPTSD) occurs in response a specific event, such as a car
various populations have been conducted (for reviews, see accident or rape. Elaborated PTSD (EPTSD) results from
Koerner & Dimeff, 2000; Koerner & Linehan, 2000), no repetitive interpersonal trauma over an extended period of
studies have examined the use of DBT for treating PTSD time. Examples of such trauma include physical, sexual,
specifically or the use of exposure in conjunction with DBT. and emotional abuse of children. Research clearly indicates
One letter to the editor was found describing the use of DBT that repetitive interpersonal trauma has more pervasive and
as a stabilization phase prior to trauma-focused therapy in long-lasting effects on the victim than circumscribed trauma
a stage-oriented trauma treatment (Lanius & Tuhan, 2003). (Herman, 1992; Herman, Russell, & Trocki, 1986). Dougher
Data was collected from 18 female patients with diagnoses and Hackbert (2000) described such a history as a long-term
of BPD and PTSD who had completed 1 year of DBT. Data establishing operation, resulting in a diverse array of social
indicated a 65% decrease in duration of inpatient stays, 45% repertoire deficits, particularly difficulty with trust and inter-
decrease in emergency room visits, and a 700% increase in personal intimacy.
employment and school attendance (only 1 patient worked Kohlenberg and Tsai (1998) discussed how the avoidance
before treatment and 8 were working or attending school af- associated with EPTSD may be quite different from that of
ter treatment). CPTSD. For example, a young child who is being physically
or sexually abused by a primary caretaker can not physically
avoid or escape the caretaker, and furthermore the child is
F UNCTIONAL A NALYTIC P SYCHOTHERAPY (FAP) dependent on this caretaker for food and other life-sustaining
functions. In this situation, successful avoidance requires
Functional Analytic Psychotherapy is a clinical behavior an- somehow isolating the relationship with the abuser during
alytic treatment based on a functional analysis of the thera- the abuse from the relationship with the abuser during other
28 MULICK, LANDES, & KANTER

times, and perhaps altering how one remembers the abusive associated with the relationship with her father such as mis-
events. Kohlenberg and Tsai speculated that such “percep- trust and vulnerability. Second, the closeness of the therapeu-
tual” avoidance may have serious consequences for the de- tic relationship allowed the client to be willing to experience
velopment of social interactions and the fundamental experi- the negative feelings evoked. Finally, the behaviors involved
ence of the self and private events. in an intimate relationship such as trusting and positive re-
According to Kohlenberg and Tsai (1998), FAP directly sponses were experienced in vivo.
targets these problems by providing in-vivo exposure to in- Prins and Callaghan (2000) presented an empirical case
terpersonal intimacy through the skillful use of the therapeu- study of FAP used as a Stage 2 treatment for PTSD. This
tic relationship as well as opportunities to shape social inter- client presented with PTSD (based on several sexual assaults
action skills and the awareness of private experience. Typical and a robbery at gun-point), Dysthymia, Alcohol Depen-
PTSD exposure protocols depend on the ability to specify the dence, Bulimia, and features of Dependent Personality Dis-
aversive stimuli and systematically expose the client to them. order. The first three years of treatment (noted as Stage 1)
With EPTSD however, it is difficult to arrange for the in-vivo included exposure for PTSD symptoms, outpatient treatment
presentation of the appropriate stimuli in an exposure-based for alcohol, CBT for bulimia, and psychopharmacology for
format. For example, in EPTSD, interpersonal intimacy and depression. Data indicated that treatment was successful in
being with a trusting partner may be seen as eliciting stim- reducing re-experiencing and hyper- arousal symptoms. The
uli and being physically or emotionally hurt are examples client also maintained sobriety for three years and stopped
of aversive stimuli. How does one arrange for exposure to purging. However, treatment was less successful in decreas-
“trust” and “intimacy” in the standard exposure protocol? ing interpersonal avoidance and detachment.
FAP solves this problem because the therapy relationship it- Stage 2 of treatment began at the start of the fourth year of
self is seen as one in which trust and intimacy genuinely oc- therapy when the client relapsed on substance abuse and re-
cur; thus, aversive and avoidance responses to these vague ported significant isolation and detachment from others; FAP
and difficult -to- define stimuli will occur in the therapy rela- was initiated at this time and lasted nine months. The treat-
tionship and can be targeted with exposure procedures. ment target was now interpersonal intimacy through disclo-
Importantly, the therapy relationship not only provides sure. Outcomes were assessed using a self-report measure-
an opportunity for extinction and habituation of respondent ment system developed specifically for FAP , in which five
fear responses to trust and intimacy, it also provides an op- classes of CRBs are identified and assessed through client
portunity for the therapist to shape a more pro-social oper- self-report. The CRBs identified included problems with
ant repertoire. Depending on the specific conceptualization under-disclosing (difficulty identifying appropriate context),
(Kohlenberg & Tsai, 2000), FAP therapists observe, evoke, failure to disclose (escape or avoidance), and failure to solicit
and naturally reinforce in-vivo occurrences of these behav- or respond to others’ disclosure. Results indicated that avoid-
iors, such as tacting and expressing feelings and other pri- ance of interpersonal closeness behaviors decreased and ear-
vate events directly, asking for what one needs, discussing lier treatment gains in regard to PTSD symptoms remained
conflict appropriately, trusting the therapist, and so on. stable. Data also indicated a decrease in CRB1s (problem
One qualitative case study and one empirical case study behaviors, such as non-disclosing) and an increase in CRB2s
of the use of FAP in the treatment of EPTSD have been con- (improvements such as self-disclosure). Overall improve-
ducted. Kohlenberg and Tsai (1998) presented a qualitative ments at the end of treatment included an increase in fre-
case study of a client treated by Dr. Tsai for six years. The quency and effectiveness of social interactions, abstinence
client had been a victim of rape and suspected past childhood from alcohol, decreased health care utilization, and increased
abuse by her father. She entered treatment because of anx- responsibility for choices.
iety, insomnia, recurring nightmares of the rape, and wak-
ing flashbacks of imagined rape. She also reported difficulty
in and avoidance of close personal relationships, which was
C ONCLUSION
conceptualized as avoidance of evocative stimuli associated
with the trauma. The primary goal of therapy was to reduce
avoidance of intimacy in the therapeutic relationship to aid There is no question that the field of psychology has made
in reduction of avoidance of intimacy in other interpersonal dramatic gains in the treatment of PTSD over the last quar-
relationships. Simply put, the therapist exposed the client ter century, particularly within the realm of cognitive- be-
to caring that was not followed by hurt. An increase in inti- havioral interventions. Despite these gains, researchers have
macy with the therapist allowed the client to recall her trauma consistently found limitations with these interventions. The
through exposure. Dr. Tsai also encouraged the client to ask contextual behavior therapies described in this paper may ad-
for her needs to be met. One example of this was letting the dress some of these limitations. This review suggests that
client set the length and frequency of sessions. CRB2s that there is a growing body of data which supports the use of
occurred for this client included remembering and emotion- contextual behavior interventions for Post-traumatic Stress
ally responding to trauma, asking for her needs to be met, Disorder. The theoretical rationale associated with each of
trusting, and accepting love. Kohlenberg and Tsai stated this the therapies, explicitly their contextual focus on avoidance
client’s therapy for EPTSD was successful for three reasons. behaviors, suggests that they maybe well suited for trauma-
First, the therapeutic relationship evoked negative feelings tized populations. It is obvious from this review that we are
 CONTEXTUAL BEHAVIOR THERAPIES IN THE TREATMENT OF PTSD 29
at the very beginning of our exploration of contextual behav- American Psychiatric Association. (1968). Diagnostic and statisti-
ior therapies in the treatment of PTSD. Much more research cal manual of mental disorders (2nd ed.).Washington, D.C.: Au-
is needed to determine the effectiveness of these treatments thor.
as stand-alone interventions, integrated with each other (Fol- American Psychiatric Association. (1980). Diagnostic and statis-
lette, Palm, & Rasmussen Hall, 2004), or integrated with tra- tical manual of mental disorders (3rd ed.). Washington, D.C.:
ditional exposure-based interventions. Author.
The field needs to be deliberate in its exploration. Re- American Psychiatric Association. (1987). Diagnostic and statisti-
searchers need to design studies carefully incorporating the cal manual of mental disorders (3rd ed. Rev.). Washington, D.C.:
Author.
findings from experiments conducted throughout the contex-
tual domain. Often the temptation in research is to demon- American Psychiatric Association. (1994). Diagnostic and statis-
strate how interventions are distinct from each other, rather tical manual of mental disorders (4th ed.). Washington, D.C.:
Author.
then exploring how they are similar. Contextual behavior
therapies allow us to look at variations of therapeutic tech- American Psychiatric Association. (2000). Diagnostic and statisti-
cal manual of mental disorders (4th ed., text revised). Washing-
niques that have similar theoretical foundations. Addition- ton, D.C.: Author.
ally, research in this area has to be held to the same standards
Batten, S. V., & Hayes, S. C. (in press). Acceptance and Com-
as the research that is being conducted on more traditional
mitment Therapy in the treatment of comorbid Substance Abuse
PTSD interventions. Consequently, as much as possible, we and Posttraumatic Stress Disorder: A case study. Clinical Case
need to try to adhere to the “gold standards” (Foa & Mead- Studies.
ows, 1997, p. 453) of treatment outcome research. Foa and Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S. Zlotnick, C., Za-
Meadows provided seven parameters for methodologically narini, M. C., Sanislow, C. A., Skodol, A. E., Gunderson, J. G.,
sound outcome research: 1) clearly defined target symptoms; Grilo, C. M., McGlashan, T. H., & Morey, L. C. (2004). Child-
2) reliable and valid measures; 3) use of blind evaluators; 4) hood maltreatment associated with adult personality disorders:
assessor training; 5) manualized, replicable, specific treat- Findings from the collaborative longitudinal personality disor-
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It is important to clarify how these standards may differ therapy of depression. New York: Guilford.
when applied to contextual behavior therapies. First, “clearly Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psy-
defined target symptoms” does not demand that the inter- chologists’ attitudes towards and utilization of exposure therapy
ventions directly target symptom reduction, rather to allow for PTSD. Behaviour Research and Therapy, 42, 277- 292.
comparisons across studies we need to have clearly defined Blake, D. D., & Sonnenberg, R. T. (1998). Outcome research on
inclusion and exclusion criteria. Simply put, while mecha- behavioral and cognitive- behavioral treatments for trauma sur-
nistic and contextual therapists have fundamental differences vivors. In V. M. Follette, J. I. Ruzek, and F. R. Abueg (Eds.),
in how they view psychopathology, this does not negate Cognitive-behavioral therapies for trauma (pp. 15-47). New
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the need for common points of comparison. Second, some
may debate how contextual behavior therapies can fall into Breslau, N., Kessler, R. C., Chilcoat, H. D., Schultz, L. R., Davis,
a “manualized, replicable, specific treatment program” and G. C., & Andreski, P. (1998). Trauma and Posttraumatic Stress
Disorder in the community: The 1996 Detroit Area Survey of
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Cook, J. M., Schnurr, P. P., & Foa, E. B. (2004). Bridging the gap
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cussed in this paper have substantial writings addressing the tice: The example of exposure therapy. Psychotherapy: Theory,
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Rosen, G. M., & Davison, G. C. (2003). Psychology should list em-
pirically supported principles of change (ESPs) and not creden- Patrick S. Mulick, Ph.D.
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Modification, 27, 300-312. Gonzaga University
Rothbaum, B. O., Meadows, E. A., Resick, P., & Foy, D. W. (2000). Spokane, WA 99258
Cognitive-behavioral therapy. In E. B. Foa, T. M. Keane, & M. J. Phone: (509) 323-6494
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(pp. 60-83). New York: Guilford. Sara J. Landes, MA
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