A New Transdiagnostic Psychotherapy for Veterans With Affective Disorders: Transdiagnostic Behavior Therapy (TBT)

Transdiagnostic treatments are based on the notion that various evidence-based psychotherapy protocols contain overlapping components designed to address common underlying symptoms found across groups of disorders (Barlow, Allen, & Choate, 2004). This is particularly true for the affective disorders, including the depressive, anxiety, obsessive-compulsive, and trauma-related disorders and their disorder-specific treatments (DSTs). Several transdiagnostic treatment protocols have been developed for and studied in groups of affective disorders based on this hypothesis, each with its own strengths and weaknesses (Norton & Paulus, 2017).

Among the available options, one transdiagnostic protocol, Transdiagnostic Behavior Therapy (TBT), was developed specifically for and evaluated in veterans (Gros, 2014). In addition to its relatively unique inclusion of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) symptomatology due to their prevalence in veterans (Magruder et al., 2005), TBT’s novelty also lies in its easy-to-disseminate and easy-to-implement format designed for Department of Veterans Affairs (DVA) providers, as compared to the other primarily anxiety-disorder-focused, multicomponent transdiagnostic protocols (Norton & Paulus, 2017). The unifying symptom targeted by TBT is transdiagnostic avoidance via four different types of exposure techniques for negative emotions: situational, interoceptive, imaginal, and (positive) emotional/behavioral activation. Once daily exposure practices are regimented, optional modules can be incorporated to further improve exposure practices (e.g., sleep hygiene).

To date, several initial trials have been investigated for TBT. First, two pilot trials (ns = 15 and 29) were completed, each of which demonstrated significant treatment improvements with large effect sizes across all disorders and comorbidities studied. Second, a small dissemination effort was completed, involving a four-hour TBT training with 28 volunteer DVA providers. Of the providers who endorsed using TBT with their patients (50%), perceived effectiveness was rated very good to excellent at six-month posttraining and corroborated by significant patient outcome data (n = 16). Third, an evaluation of a group version of TBT (n = 34) was compared to DST groups (n = 66) with large effect sizes observed in both groups. Finally, a randomized clinical trial (RCT) comparing TBT (n = 44) and behavioral activation (BA) (n = 46) was completed with results demonstrating larger treatment effects for TBT than BA in symptoms of depression and anxiety. Across each study with a comparison group, TBT generally demonstrated larger effect sizes compared to DSTs, a finding not shared in studies of the other transdiagnostic treatments (Barlow et al., 2017; Norton & Paulus, 2017).

Although the potential for TBT is clear, additional research is needed to further investigate its potential as a treatment of choice for the affective disorders. Most significantly, more studies are needed with random assignment to treatment condition with matching DSTs. Studies should include large sample sizes to compare TBT and matching DSTs across the diagnostic groups and comorbidities. In addition, a more rigorous dissemination study is needed to better understand the success of the proposed four-hour training. Together, the further study of TBT will promote better understanding of the initial findings of improved outcomes and ease of dissemination compared to the existing DSTs, resulting in improved outcomes and access for veterans with affective disorders.