Clinical Psychology in Europe (E-Journal)
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Responding to Key Process Markers as a Focus of Psychotherapy Training and Practice
No full textHistorically, evidence-based psychotherapy training has favored the standardized application of discrete treatment packages, with key outcomes being the therapist’s adherence to and competent delivery of theory-prescribed ingredients. However, this model often fails to align with the priorities and values of clinicians, and research casts doubt on the notion that a therapist’s faithful application of treatment protocols is a valid index of clinical expertise. Considering this, training and practice models that emphasize evidence-based clinician flexibility and patient-centered tailoring of interventions are receiving increased attention. In this article, we outline one such model informed by the context-responsive psychotherapy integration (CRPI) framework. Consistent with CRPI principles, we describe several “if this/then try that” marker-response sequences that could become a centerpiece of a more nuanced, clinically representative, and evidence-based psychotherapy training paradigm. Finally, we offer several recommendations for future work on CRPI
Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression
No full textBackground: To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity. Method: 150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator. Discussion: Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression. Trial registration: The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116)
Cognitive Symptoms Link Anxiety and Depression Within a Validation of the German State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA)
No full textBackground: In the present study we aimed to develop a German version of the State-Trait Inventory for Cognitive and Somatic Anxiety (STICSA) and evaluate the psychometric properties. Associations of cognitive and somatic anxiety with other measures of anxiety, depression, and stress, elucidating possible underlying functional connections, were also examined, as symptoms of anxiety, depression and stress often overlap. Method: Two samples (n1 = 301; n2 = 303) were collected online and in the lab, respectively. Dynamic connections between somatic and cognitive anxiety, other measures of anxiety, depression, and stress, were analyzed using a network approach. Psychometric analyses were conducted using exploratory and confirmatory factor analyses. Results: We replicated and validated the two-factorial structure of the STICSA with the German translation. Network analyses revealed cognitive trait anxiety as the most central node, bridging anxiety and depression. Somatic trait anxiety exhibited the highest discriminant validity for distinguishing anxiety from depression. Conclusion: The central role of cognitive symptoms in these dynamic interactions suggests an overlap of these symptoms between anxiety and depression and that differential diagnostics should focus more on anxious somatic symptoms than on cognitive symptoms. The STICSA could therefore be useful in delineating differences between anxiety and depression and for differential assessment of mood and anxiety symptoms. Additional understanding of both cognitive and somatic aspects of anxiety might prove useful for therapeutic interventions
How and Why the Choice of Success Criteria Can Impact Therapy Service Delivery: A Worked Example From a Psychological Therapy Service for Anxiety and Depression
No full textBackground: Well-defined measures of therapeutic benefit are essential for evaluating therapies and services. However, there is no single gold standard for defining ‘successful’ outcomes. We therefore examined the potential impact of adopting different success criteria. Method: We analysed data for 7,064 patients undergoing psychological therapy in a single UK IAPT (Increasing Access to Psychological Therapy) Service, each patient being assessed for depression (PHQ-9) and anxiety (GAD-7) both at the start and end of treatment. Predictors of successful outcomes based on these measures were analysed separately for three different success criteria: based either on assessing clinically significant change, or reliable change, in depression and anxiety. Results: The choice of criteria had little bearing on which variables predicted successful outcomes. However, the direction of the relationship between initial PHQ-9 or GAD-7 score and outcome success reverses when the criteria used to judge success are changed: successful outcomes are less probable under clinically significant change criteria for patients entering the service with more severe depression and/or anxiety but are more probable for such patients under reliable change criteria. Conclusion: Relevant for clinicians, researchers, and policymakers, the choice of success criteria adopted can substantially change the incentives for patient selection into a therapy service. Our analysis highlights how the methods used to evaluate treatment outcomes could impact the priorities and organisation of therapeutic services, which could then impact on who is offered treatment. We recommend further investigations of success criteria in other conditions or treatments to determine the reproducibility of the effects we found
Health Scares: Tracing Their Nature, Growth and Spread
No full textBackground: Health scares are highly publicised threats to health that increase public concern and protective behaviours but are later shown to be unfounded. Although health scares have become more common in recent times, they have received very little research attention. This is despite the fact that health scares often have negative outcomes for individuals and community by affecting health behaviours and causing high levels of often unnecessary anxiety. Method: In this paper we undertook a review and analysis of the major types of health scares as well as the background factors associated with health scares and their spread. Results: We found most health scares fell into seven main categories; environmental contaminants, food, malicious incidents, medical treatments, public health interventions, radiation from technology and exotic diseases. For most health scares there are important background factors and incident characteristics that affect how they develop. Background factors include conspiracy theories, trust in governmental agencies, anxiety, modern health worries and wariness of chemicals. Incident characteristic include being newly developed, not understood or unseen, man-made rather than natural and whether the incident is out of personal control. We also identified the aspects of traditional and social media that exacerbate the rapid spread of health scares. Conclusion: More research is needed to identify the characteristics of media stories that intensify the levels of public concern. Guidelines around the media’s reporting of health incidents and potential health threats may be necessary in order to reduce levels of public anxiety and the negative public health impact of health scares
The Role of Expectancy Violation in Extinction Learning: A Two-Day Online Fear Conditioning Study
No full textBackground: Exposure therapy is at the core of the treatment of pathological anxiety. While the inhibitory learning model proposes a framework for the mechanisms underlying exposure therapy, in particular expectancy violation, causal evidence for its assumptions remains elusive. Therefore, the aim of the current study was to provide evidence for the influence of expectancy violation on extinction retention by manipulating the magnitude of expectancy violation during extinction learning. Method: In total, 101 individuals completed a web-based fear conditioning protocol, consisting of a fear acquisition and extinction phase, as well as a spontaneous recovery and fear reinstatement test 24h later. To experimentally manipulate expectancy violation, participants were presented only with states of the conditioned stimulus that either weakly or strongly predicted the aversive outcome. Consequently, the absence of any aversive outcomes in the extinction phase resulted in low or high expectancy violation, respectively. Results: We found successful fear acquisition and manipulation of expectancy violation, which was associated with reduced threat ratings for the high compared to the low expectancy violation group directly after extinction learning. On Day 2, inhibitory CS-noUS associations could be retrieved for expectancy ratings, whereas there were no substantial group differences for threat ratings. Conclusion: These findings indicate that the magnitude of expectancy violation is related to the retrieval of conscious threat expectancies, but it is unclear how these changes translate to affective components (i.e., threat ratings) of the fear response and to symptoms of pathological anxiety
Research Into Evidence-Based Psychological Interventions Needs a Stronger Focus on Replicability
No full textBackground: It is a precondition for evidence-based practice that research is replicable in a wide variety of clinical settings. Current standards for identifying evidence-based psychological interventions and making recommendations for clinical practice in clinical guidelines include criteria that are relevant for replicability, but a better understanding as well refined definitions of replicability are needed enabling empirical research on this topic. Recent advances on this issue were made in the wider field of psychology and in other disciplines, which offers the opportunity to define and potentially increase replicability also in research on psychological interventions. Method: This article proposes a research strategy for assessing, understanding, and improving replicability in research on psychological interventions. Results/Conclusion: First, we establish a replication taxonomy ranging from direct to conceptual replication adapted to the field of research on clinical interventions, propose study characteristics that increase the trustworthiness of results, and define statistical criteria for successful replication with respect to the quantitative outcomes of the original and replication studies. Second, we propose how to establish such standards for future research, i.e., in order to design future replication studies for psychological interventions as well as to apply them when investigating which factors are causing the (non-)replicability of findings in the current literature
Mirror Exposure Training for Adolescents With Anorexia Nervosa (MIRADAN): Cognitive Mechanisms of Body Disturbance – A Study Protocol
No full textBackground: Anorexia Nervosa (AN) is a severe mental illness, which typically develops in adolescence and, if left untreated, often becomes chronic. Body dissatisfaction is a core characteristic of AN. Mirror exposure (ME) is an effective therapeutic technique to tackle body dissatisfaction in adult patients with eating disorders, but there is limited evidence for the effects of ME in adolescence. One potential mechanism underlying effects of ME on body dissatisfaction is change in body-related attention bias. However, this mechanism remains to be empirically tested. Accordingly, the aim of the current study is twofold: primarily, we aim to test if ME can reduce body dissatisfaction and associated symptoms in adolescent patients with AN. Additionally, we aim to investigate whether change in biased body-related attention due to ME is a possible mechanism of action. Method: Adolescent patients with AN are randomized to either 12 sessions of ME (3 ME-sessions/week) or wait-list within four weeks. Main outcomes include body dissatisfaction and associated symptoms of AN. Moreover, body-related attention bias is assessed at baseline and post-treatment by means of eye-tracking with two paradigms. Further, process variables are collected weekly. In addition, 12 weeks after end of the study, the acceptability of the ME is assessed. Discussion: The main aim of the study is to evaluate high-frequency and high-intense ME for treating body dissatisfaction in adolescents with AN. In addition, we would like to clarify whether change in attentional bias for body stimuli is a mechanism underlying change in body dissatisfaction due to ME
Interoception and Premonitory Urges in Children and Adolescents With Tic Disorders
No full textBackground: Compared to healthy controls (HCs), adult Tic Disorder (TD) patients exhibit a lower interoceptive accuracy (IAcc) in heartbeat perception. Since the lower IAcc is not evident in children, the age at which tics develop, but in adults only (Pile et al., 2018, https://doi.org/10.1007/s10803-018-3608-8), lower IAcc may reflect a pathological mechanism relevant with regard to tics, premonitory urges (PUs) or the resulting impairment. Although tics are a motor phenomenon, up to date, IAcc has been assessed only with a heartbeat-counting task. This study aims at comparing cardiac and muscular IAcc using two different paradigms and investigates how IAcc is related to premonitory urges in youth. Method: Interoceptive measures (heartbeat-counting task, muscle tension paradigm) of 28 youth with TD were compared to 23 control participants and related to self-rated premonitory urges and tic symptoms. Results: TD patients did not differ from HCs in any IAcc measures. However, within TD patients, IAcc explained additional variance in PUs when controlling for tic severity. Muscular IAcc in TD patients is related to urges and tics, but the direction of this association is unclear. IAcc is lower in TD patients than in HCs, indicating imprecise sensory input which is more easily overcome by priors within the predictive coding framework. Conclusions: Muscle tension feedback tasks could extend interoceptive trainings aimed at improving IAcc to improve accuracy of urge perception (more precise sensory input) to foster the ability to control tics via HRT. Longitudinal studies could provide further insights in causal relationships between IAcc, premonitory urges and tics