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The Official Publication of the Philadelphia Behavior Therapy Association

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  • 03/26/2024 2:14 PM | Anonymous

    Gabriele Wilz, PhD - Friedrich-Schiller-Universität (Friedrich Schiller University Jena)

    People caring for an older family member, or a family member with dementia, are at high risk for developing health impairments such as exhaustion and depressive symptoms (Collins & Kishita, 2019; Kaddour & Kishita, 2019). As the population ages and caring for a family member becomes more and more common, there is an urgent need to bolster family caregivers’ (CGs) resilience. There is robust evidence that psychotherapeutic interventions can effectively improve family CGs mental health and quality of life (Cheng et al., 2019; Toepfer et al., 2021). A primary focus of psychotherapy with family caregivers should be addressing CGs dysfunctional and functional thoughts about caregiving (Risch et al., 2022; Wilz, 2023).

    Cognitions Moderate the Experience of Caregiving

    The family caregiving situation can certainly be characterized as a chronically and highly demanding situation. Nevertheless, people react to the demands of caregiving very differently. Some people experience caregiving as manageable or even rewarding, while other people suffer intensely. How a person experiences caregiving depends to some extent on their own, subjective appraisals and evaluations of the situation. According to the transactional stress model (Lazarus & Folkman, 1984) and generic cognitive models of depression and mental diseases (Beck & Haigh, 2014), cognitive appraisal processes play a decisive role in how people react to stressful situations and the formation of mental illness. Likewise, family CGs automatic thoughts and attitudes are seen as key determinants of their ability to contend with the strains (Risch et al, 2022; Losada, Montorio et al., 2006) and experience the positive aspects (Yu et al., 2018) of caregiving.

    As Losada, Montorio, and colleagues (2006) describe, there are pathological and healthy cognitive pathways in caregiving. Dysfunctional thoughts and attitudes, such as perfectionism, unrealistic goals and standards, and irrational interpretations of the care recipient’s behavior are common (Risch et al., 2022). Among family caregivers, dysfunctional cognitions are strongly associated with the perceived burden of caregiving (Vázquez-Sánchez et al. 2012), physical and mental stress (Losada et al., 2011; McNaughton et al., 1995; Sullivan et al., 2016) and depression (Márquez-González et al., 2007; McNaughton et al., 1995). Moreover, CGs dysfunctional cognitions can elicit a negative emotional response towards the care recipient, which in turn can instigate a negative cycle of problematic interactions between the caregiver and care recipient (Losada, Montorio, et al., 2006). In contrast, caregivers who have functional cognitions about caregiving (e.g., high caregiving self-efficacy; confidence that one is able to manage the demands of caregiving) are more likely to experience positive aspects of caregiving (Semiatin & O’Conner, 2012).

    Although well-established theoretical models and existing empirical evidence both point to family CGs cognitions as key determinants of their resilience, few caregiver intervention concepts have explicitly aimed to modify cognitions as a treatment goal (Wilz, 2023). The few existing studies found that cognitive behavior therapy (CBT) reduced CGs depression specifically by reducing their dysfunctional thoughts (Losada et al., 2011; Márquez-Gonzalez et al., 2007). These findings substantiate the importance of addressing CGs care-related cognitions in psychotherapeutic interventions.

    Which Cognitions Matter? Four Domains of Dysfunctional and Functional Care-related Cognitions

    Risch and colleagues (2022) proposed four domains of dysfunctional and functional care-related cognitions particularly relevant for family caregivers of people with dementia:

    (1) Dysfunctional caregiving standards include a sense of bearing the sole responsibility for caregiving; perfectionism; and self-blame when caregiving ideals have not been met. Beliefs that caregiving “must” be provided on one’s own, or that “strangers” could not provide adequate care, may prevent caregivers from utilizing professional and informal sources of support. Some caregivers may see their need for support as a personal failure. Caregivers may feel guilty or ashamed if they think they are  unable to provide adequate care on their own, or that they have fallen short of their own ideals. They may feel guilty delegating responsibility to someone else, even temporarily, or devoting time and attention to their own needs. Indeed, family caregivers of people with dementia with higher dysfunctional caregiving standards tend to have worse mental health (Cabrera et al., 2021; Losada et al., 2010; Losada, Robinson Shurgot, et al., 2006; McNaughton et al., 1995; Risch et al., 2022).

    (2) Dysfunctional thoughts and attitudes about dementia include misinterpretations of the care recipient’s behavior; irrational expectations; and inaccurate assumptions about the pathogenesis and course of the disease. Family members often experience the behavioral symptoms of dementia as expressions of spite, ignorance, or defiance. Such misinterpretations can be emotionally burdensome and lead to conflicts with the care recipient. Some family caregivers harbor the belief that their past behavior caused their family member to develop dementia. Among family caregivers of people with dementia, more accurate knowledge about dementia and caregiving may predict better mental health, while dysfunctional attitudes toward dementia have been associated with higher depression and anxiety (Risch et al., 2022).

    (3) Functional thoughts and attitudes about self-care include CGs beliefs about leisure and regeneration, and the importance of recovery for the quality of care. Clinical experience suggests that caregivers who take care of themselves tend to cope better with the caregiving situation over the long term. Positive beliefs about self-care might help caregivers to acknowledge their own needs and individual limits, and enable them to mentally distance themselves from the caregiving situation when appropriate. Evidence suggests that caregivers who engage in more self-care and leisure activities, and perceive more leisure time, also perceive less burden and have better mental health (Losada et al., 2010; Romero-Moreno et al., 2011; Schüz et al., 2015; Waligora et al., 2018). Based on their literature review, Oliveira and colleagues (2019) concluded that interventions designed to improve CGs health and lifestyle improved CGs depression, perceived burden, and quality of life.

    (4) Functional thoughts and attitudes concerning acceptance include assumptions about the controllability of the caregiving situation; how caregivers process negative, unchangeable events; and detachment in stressful situations (i.e., taking the perspective of an observer who is less affected by the situation; Kalish et al., 2005). According to the model of acceptance and commitment therapy (ACT; see Hayes et al., 2006), acceptance is the willingness to experience unchangeable, adverse external (e.g., a family member’s dementia diagnosis) and internal (e.g., negative emotions and thoughts) events without trying to avoid or suppress them (e.g., denial, substance use). Among family caregivers, acceptance is associated with better mental health (Risch et al., 2024; Losada et al., 2015) and lower depression (Spira et al., 2007). In contrast, the avoidance or suppression of negative thoughts and emotions (i.e., experiential avoidance) is associated with worse depression, anxiety, physical health, and health-related quality of life (Risch et al., 2024; Goodwin & Emery, 2016; Wenze et al., 2018). Functional thoughts and attitudes concerning acceptance are associated with lower depression and anxiety in family caregivers of people with dementia (Risch et al., 2022, 2024). Caregivers who approach the caregiving situation with a certain degree of detachment and a high degree of acceptance may be able to react to stressful situations more pragmatically and permit themselves more leisure time.

    Strategies for Addressing CGs Care-related Cognitions

    Interventions for family caregivers of people with dementia should aim to reduce dysfunctional attitudes towards dementia and dysfunctional caregiving standards while, at the same time, also aim to foster functional cognitions related to self-care and acceptance. In the first sessions of work with CGs, psychotherapists should therefore focus on uncovering and identifying CGs own, individual automatic and unconscious thought patterns. The questionnaire from Risch and colleagues (2022) can aid in the assessment of family CGs dysfunctional and functional cognitions about caregiving.

    In the next step, therapists should work with family caregivers to clarify the links between the caregiver’s dysfunctional (unhelpful) cognitions on the one hand, and their behavior, emotions and experience of burden on the other hand. Acknowledging factors such as incongruence; role discrepancies; motives for caregiving; and social, cultural, and familial norms as reference points for self-appraisals can support developing clarity and new constructive perspectives. Once the links between specific cognitions and specific caregiving experiences have been established, caregivers are in a better position to resolve conflicts between their caregiving tasks and their own values and needs; clarify their motivation for caregiving; and approach their caregiving decisions more deliberately. Subsequently, CGs dysfunctional cognitions can be evaluated, questioned and re-negotiated. Through Socratic dialogue, guided discovery, and Ellis’ ABC Model (A: Activating Event, B: Beliefs, C: Consequences, Ellis, 1973), the therapist and caregiver can work out alternative, more helpful ways of thinking as well as possibilities to practice these new ways of thinking in real life.

    Approaches based on ACT are conducive to strengthening family CGs functional cognitions about self-care and acceptance. In line with an ACT-based approach, therapists should direct their focus toward helping caregivers come to terms with the unchangeable aspects of the care recipient’s condition and the caregiving situation. It can be particularly helpful to facilitate the expression of distressing emotions and coping with loss and grief. Therapists can also employ ACT-based approaches to encourage family caregivers to live in closer alignment with their own values and needs (Risch et al., 2024).

    In sum, psychotherapists working with family caregivers should consider following an integrative approach combining aspects of CBT and ACT that together address CGs dysfunctional and functional cognitions about caregiving while supporting skillful relationship with the challenges inherent in the CGs role. The Tele.TAnDem intervention concept is an effective psychotherapeutic intervention for family caregivers based primarily on CBT and ACT (Wilz, 2023). The manual provides comprehensive and specific guidance on how therapists can work with caregivers to recognize debilitating thought patterns, and develop alternative, potentially stress-reducing and encouraging ways of thinking.

    Beck, A. T., & Haigh, E. A. P. (2014). Advances in cognitive theory and therapy: The generic cognitive model. Annual Review of Clinical Psychology, 10, 1-24.

    Cabrera, I., Márquez-González, M., Kishita, N., Vara-García, C., & Losada, A. (2021). Development and validation of an Implicit Relational Assessment Procedure (IRAP) to measure implicit dysfunctional beliefs about caregiving in dementia family caregivers. The Psychological Record, 71(1), 41-54.

    Cheng, S.-T., Au, A., Losada, A., Thompson, L.W. & Gallagher-Thompson, D. (2019). Psychological interventions for dementia caregivers: What we have achieved, what we have learned. Current Psychiatry Reports, 21(59), 1-12.

    Collins, R. N., & Kishita, N. (2019). Prevalence of depression and burden among informal caregivers of people with dementia: A meta-analysis. Ageing & Society, 40(11), 1-38.

    Ellis, A. (1973). Humanistic psychotherapy: The rational-emotive approach. New York: McGraw-Hill.

    Goodwin, C.L., & Emery, C.F. (2016). Lower experiential avoidance is associated with psychological well-being and improved cardiopulmonary endurance among patients in cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention, 36(6), 438-444.

    Hayes, S.C., Luomaa, J.B., Bond, F.W., Masudaa, A., & Lillies, J. (2006). Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44(2006), 1–25.

    Kaddour, L., & Kishita, N. (2019). Anxiety in informal dementia carers: A meta-analysis of prevalence. Journal of Geriatric Psychiatry and Neurology, 33, 161-172.

    Kalisch, R., Wiech, K., Critchley, H.D., Seymour, B., O'Doherty, J.P., Oakley, D.A., Allen, P., & Dolan, R.J. (2005). Anxiety reduction through detachment: Subjective, physiological, and neural effects. Journal of Cognitive Neuroscience, 17(6), 874-83. https:// doi:10.1162/0898929054021184

    Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer.

    Losada, A., Márquez-González, M., & Romero-Moreno, R. (2011). Mechanisms of action of a psychological intervention for dementia caregivers: Effects of behavioral activation and modification of dysfunctional thoughts. International Journal of Geriatric Psychiatry, 26(11), 1119–1127.

    Losada, A., Márquez-González, M., Romero-Moreno, R., Mausbach, B.T., López, J., Fernández-Fernández, V., & Nogales-González, C. (2015). Cognitive-behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for dementia family caregivers with significant depressive symptoms: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 83(4), 760-772.

    Losada, A., Montorio, I., Knight, B.G., Márquez, M., & Izal, M. (2006). Explanation of caregivers distress from the cognitive model: The role of dysfunctional thoughts. Psicología Conductual, 14(1), 115-128.

    Losada, A. Pérez-Peñaranda, A., Rodriguez-Sanchez, E., Gomez-Marcos, M.A., Ballesteros-Rios, C., Ramos-Carrera, I.R., Campo-de la Torre, Ma A., & García-Ortiz, L. (2010). Leisure and distress in caregivers for elderly patients. Archives of Gerontology and Geriatrics, 50(3), 347-350.

    Losada, A., Robinson Shurgot, G., Knight, B. G., Márquez, M., Montorio, I., Izal, M., & Ruiz, M. A. (2006). Cross-cultural study comparing the association of familism with burden and depressive symptoms in two samples of Hispanic dementia caregivers. Aging & Mental Health, 10(1), 69-76.

    Márquez-González, M. , Losada , A.,  Izal , M., Pérez-Rojo , G., & Montorio , I. (2007). Modification of dysfunctional thoughts about caregiving in dementia family caregivers: Description and outcomes of an intervention programme. Aging & Mental Health, 11(6), 616-625.

    McNaughton, M.E., Patterson, T.L., Smith, T.L., & Grant, I. (1995). The relationship among stress, depression, locus of control, irrational beliefs, social support, and health in Alzheimer’s disease caregivers. The Journal of Nervous and Mental Disease, 183, 78–85.

    Oliveira, D., Sousa, L. & Orrell, M. (2019). Improving health-promoting self-care in family carers of people with dementia: a review of interventions. Clinical Interventions in Aging, 14, 515-523.

    Risch, A. K., Mund, M., & Wilz, G. (2022). The Caregiver Thoughts Scale: An instrument to assess functional and dysfunctional thoughts about caregiving. Clinical Gerontologist, 4, 1-14.

    Risch, A. K., Lechner-Meichsner, F., & Wilz, G. (2024, March 23). Evaluation of telephone-based acceptance and commitment therapy for caregivers of persons with dementia. PsyArXiv.

    Romero-Moreno, R., Márquez-González, M., Mausbach, B.T., & Losada, A. (2011). Variables modulating depression in dementia caregivers: A longitudinal study. International Psychogeriatrics, 24(8), 1316-1324.

    Semiatin, A.M., & O'Connor, M.K. (2012). The relationship between self-efficacy and positive aspects of caregiving in Alzheimer's disease caregivers. Aging & Mental Health, 16(6), 683-688.

    Schüz, B., Czerniawski, A., Davie, N., Miller, L., Quinn, M. G., King, C., Carr, A., Elliott, K.-E. J., Robinson, A., & Scott, J. L. (2015). Leisure time activities and mental health in informal dementia caregivers. Applied Psychology: Health and Well-Being, 7(2), 230-248.

    Spira, A.P., Beaudreau, S.A., Jimenez, D., Kierod, K., Cusing, M.M., Gray, H.L., & Gallagher-Thompson, D. (2007). Experiential avoidance, acceptance, and depression in dementia family caregivers. Clinical Gerontologist, 30, 55–64.

    Sullivan, K.A., Beattie, E., Khawaja, N.G., Wilz, G., & Cunningham, L.C. (2016). The Thoughts Questionnaire (TQ) for family caregivers of people with dementia. Dementia, 15, 1474 - 1493.

    Toepfer, N. F., Sittler, M. C., Lechner-Meichsner, F., Theurer, C., & Wilz, G. (2021). Long-term effects of telephone-based cognitive-behavioral intervention for family caregivers of people with dementia: Findings at 3-year follow-up. Journal of Consulting and Clinical Psychology, 89(4), 341–349.

    Vázquez-Sánchez, M.Á., Aguilar-Trujillo, M.P., Estébanez-Carvajal, F.M., Casals-Vázquez, C., Casals-Sánchez, J.L., & Heras-Pérez, M.C. (2012). The influence of dysfunctional thoughts on the burden of the dependent person caregiver; Enfermeria Clinica, 22(1), 11-17.

    Waligora, K. J., Bahouth, M. N., & Han, H.-R. (2018). The self-care needs and behaviors of dementia informal caregivers: A systematic review. The Gerontologist, 59(5), e565-e583.

    Wenze, S.J., Gaugler, T.L., Sheets, E.S., & DeCicco J.M. (2018). Momentary experiential avoidance: Within-person correlates, antecedents, and consequences and between-person moderators. Behavior Research and Therapy, 107, 42-52.

    Wilz, G. (2023). Psychotherapeutic support for family caregivers of people with dementia. Hogrefe Publishing.

    Wilz, G., Reder, M., Meichsner, F., & Soellner, R. (2018). The Tele.TAnDem intervention: telephone-based CBT for family caregivers of people with dementia. The Gerontologist, 58(2), e118-e129.

    Yu, D.S.F, Cheng, S.T., & Wang, J. (2018). Unravelling positive aspects of caregiving in dementia: An integrative review of research literature. International Journal of Nursing Studies, 79, 1- 26.

  • 02/28/2024 1:42 PM | Anonymous

    Ann M Steffen, PhD - University of Missouri - St. Louis

    Synchronous (live) psychotherapy delivered via video conference or telephone-only can be an effective way to provide CBT to adult clients across the lifespan, including CBT with older adults. There is a longstanding recognition that many prospective mental health clients experience physical barriers that can be addressed through telemental healthcare. Those living in rural communities are especially unlikely to have easy access to in-person psychotherapy with a local provider. Others live with a range of acute and chronic physical health conditions that limit mobility and make attending weekly therapy sessions very difficult. Poor access to transportation compounds these challenges for many. It is important for us to recognize that none of these barriers are new. The identified need for, interest in, and research on telephone-based and video-conferenced psychotherapy are all well-established (Riper & Cuijpers, 2016). Many healthcare systems across the globe and within the US have decades of experience in providing live/synchronous teletherapy to clients (Myers & Turvey, 2012).

    For most psychotherapists, however, the initial COVID-19 lockdown created their first, and very sudden, experience with providing therapy by videoconference and/or telephone. Along with coping with other aspects of the pandemic, we lived through a wide range of challenges with this pivot away from in-person sessions. Some of these difficulties have remained for therapists who include teletherapy within their clinical practice. As we reach the four-year anniversary of the 2020 initial lock-down within the United States, it is helpful to address ongoing concerns by examining lessons learned, especially in CBT practice with older adults who are living independently in the community. Because of the complexities involved, this article will not focus on the added challenges of clinical work in the context of assisted living or skilled nursing care (interested readers are referred to resources provided by Psychologists in Long Term Care;

    Evidence Base - How confident can we be regarding our evidence base for using telehealth to provide psychotherapy?

    Does it work?  Meta-analytic reviews have evaluated both the efficacy (randomized controlled trials) and effectiveness (evaluations in routine clinical settings) of both video-conferenced and telephone-based psychotherapy compared to in-person sessions. These reviews have generally concluded that client outcomes are similar among delivery formats for clients across the adult lifespan and across a range of presenting concerns (Lin et al., 2022; Varker et al., 2019). This “equal outcomes across delivery formats” conclusion has been echoed in reviews for CBT interventions specifically (Nelson & Duncan, 2015), CBT for depression (Cuijpers et al., 2019) and with older adults (Freytag et al., 2022; Gentry et al., 2019). Individual research studies focused on older adults suggest comparable findings. Positive outcomes have been reported for telephone-delivered CBT for older, rural Veterans with depression and anxiety in home-based primary care (Barrera et al., 2017), telehealth problem-solving therapy for depressed low-income homebound older adults (Choi et al., 2014), and telehealth CBT for depression and insomnia in ethnically diverse older adults in rural south (Scogin et al., 2018). Outcomes for telehealth interventions with dementia family caregivers have also been favorable for a range of psychosocial outcomes including depression (Steffen & Gant, 2016).

    Is teletherapy acceptable to clients?  A rather important question has been whether older psychotherapy patients will accept the use of remote technology to engage with their clinician. Although some aging individuals expressed initial hesitance before beginning use in a qualitative study, most concluded after participating in a telehealth intervention that they appreciated the convenience and were able to feel emotionally connected with their provider (Choi et al., 2014). Beyond qualitative interviews with service recipients, data on attendance patterns and attrition can also answer questions about acceptability. Clients receiving telephone-based CBT have the very lowest attrition rates (i.e., are less likely to drop out of therapy prematurely), followed by those participating in video-conferencing sessions, with attrition rates highest for in-person CBT (Cuijpers et al., 2019; Cuthbert et al., 2022).

    Common Challenges

    Despite this evidence, it is clear that as CBT clinicians, we continue to experience a range of issues in our psychotherapy practices that involve video-conferencing or telephone-only sessions. Most of these challenges occur in telehealth CBT sessions with clients across the lifespan. These include a host of familiar concerns including spotty wifi and connectivity issues (or complete lack of internet access), reliance on smart phones leading to screens too small for use of printed materials or screen sharing, distractions in the home such as other people, pets, tv; increased client expectations for last-minute rescheduling of sessions, desire for more session time devoted to supportive counseling, gauging clients’ engagement in therapy, and especially challenges in assigning and reviewing between session practice forms (aka “homework’).

    Some clinicians describe concerns in their teletherapy CBT practice that are perhaps not unique to older adults but may occur more frequently. Certainly, age-associated sensory changes in vision and hearing are something that we accommodate for, whether sessions are held in person or via a different delivery format; holding sessions by video conference or telephone-only can compound these challenges. Most older adults are both familiar with and routinely use a range of technologies (Greenwald et al., 2018), yet may require more frequent reminders and additional time for managing some of the details of videoconferencing (logging in procedures, turning on video and adjusting audio levels, hiding self-view). Repeated use of a small set of printed handouts and between-session worksheets can be quite useful (Steffen et al., 2021). Importantly, anxiety about difficulties that arise when using video conferencing technologies and software can provide opportunities for therapeutic responding, including problem-solving, exposure strategies, along with other CBT interventions to address the challenges of telehealth that are associated with distress.

    Table 1 shown below, from Freytag et al. (2022) provides a nice starting point for thinking about your own ways of addressing some of these concerns.

    Table 1 from Freytag et al (2022). Reproduced with permission.
    Note: VTH refers to Video Telehealth

    Concluding Comments

    There are now a variety of resources and tips available for CBT therapists who would like to improve the impact of their telehealth sessions with older adults. These include strategies to manage procedural aspects of telehealth sessions, develop and maintain therapeutic rapport, and enhance therapy effectiveness with older adult clients.

    Barrera, T. L., Cummings, J. P., Armento, M., Cully, J. A., Bush Amspoker, A., Wilson, N. L., & ... Stanley, M. A. (2017). Telephone-delivered cognitive-behavioral therapy for older, rural Veterans with depression and anxiety in home-based primary care. Clinical Gerontologist: The Journal Of Aging And Mental Health, 40(2), 114-123. doi:10.1080/07317115.2016.1254133

    Choi NG, Hegel MT, Marti N, Marinucci ML, Sirrianni L, Bruce ML. (2014), Telehealth problem-solving therapy for depressed low-income homebound older adults. Am J Geriatr Psychiatry. 2014 Mar;22(3):263-71. doi: 10.1097/JGP.0b013e318266b356.

    Choi NG, Wilson NL, Sirrianni L, Marinucci ML, Hegel MT. (2014), Acceptance of home-based telehealth problem-solving therapy for depressed, low-income homebound older adults: qualitative interviews with the participants and aging-service case managers. Gerontologist, 54(4):704-13. doi: 10.1093/geront/gnt083.

    Cuijpers, P., Noma, H., Karyotaki, E., Cipriani, A., & Furukawa, T. A. (2019). Effectiveness and acceptability of cognitive behavior therapy delivery formats in adults with depression: a network meta-analysis. JAMA Psychiatry, 76(7), 700-707.

    Cuthbert, K., Parsons, E. M., Smith, L., & Otto, M. W. (2022). Acceptability of telehealth CBT during the time of COVID-19: evidence from patient treatment initiation and attendance records. Journal of behavioral and cognitive therapy, 32(1), 67-72.

    Freytag J, Touchett HN, Bryan JL, Lindsay JA, Gould CE. Advances in Psychotherapy for Older Adults Using Video-to-Home Treatment. Adv Psychiatry Behav Health. 2022 Sep;2(1):71-78. doi: 10.1016/j.ypsc.2022.03.004. Epub 2022 Sep 9. PMID: 38013747; PMCID: PMC9458515.

    Gentry, M. T., Lapid, M. I., & Rummans, T. A. (2019). Geriatric telepsychiatry: systematic review and policy considerations. The American Journal of Geriatric Psychiatry, 27(2), 109-127.

    Greenwald, P., Stern, M. E., Clark, S., & Sharma, R. (2018). Older adults and technology: In telehealth, they may not be who you think they are. International Journal of Emergency Medicine, 11(1), 2–4.

    Lin, T., Heckman, T. G., & Anderson, T. (2022). The efficacy of synchronous teletherapy versus in-person therapy: A meta-analysis of randomized clinical trials. Clinical Psychology: Science and Practice, 29(2), 167–178.

    Luxton, D. D., Nelson, E. L., & Maheu, M. M. (2022). A practitioner's guide to telemental health: How to conduct legal, ethical, and evidence-based telepractice. 2nd edition. American Psychological Association.

    Myers, K., & Turvey, C. (Eds.). (2012). Telemental health: Clinical, technical, and administrative foundations for evidence-based practice. Newnes.

    Nelson, E.-L., & Duncan, A. B. (2015). Cognitive behavioral therapy using televideo. Cognitive and Behavioral Practice, 22(3), 269–280.

    Riper, H., & Cuijpers, P. J. (2016). Telepsychology and eHealth. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, & R. Krishnamurthy (Eds), APA handbook of clinical psychology: Applications and methods, Vol. 3, (pp. 451-463). Washington, DC, US: American Psychological Association, xvi,

    Scogin, F., Lichstein, K., DiNapoli, E. A., Woosley, J., Thomas, S. J., LaRocca, M. A., Byers, H. D., Mieskowski, L., Parker, C. P., Yang, X., Parton, J., McFadden, A., & Geyer, J. D. (2018). Effects of integrated telehealth-delivered cognitive-behavioral therapy for depression and insomnia in rural older adults. Journal of Psychotherapy Integration, 28(3), 292–309.

    Steffen, A.M., Dick-Siskin, L., Bilbrey, A., Thompson, L.W., & Gallagher-Thompson, D. (2021). Treating Later-Life Depression: A Cognitive Behavioral Approach Workbook. 2nd edition, 358 pages. Treatments that Work Series; Oxford University Press.

    Steffen, A. M., & Gant, J. R. (2016). A telehealth behavioral coaching intervention for neurocognitive disorder family carers. International Journal Of Geriatric Psychiatry, 31(2), 195-203. doi:10.1002/gps.4312

    Varker, T., Brand, R., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of Synchronous Telepsychology Interventions for People With Anxiety, Depression, Posttraumatic Stress Disorder, and Adjustment Disorder: A Rapid Evidence Assessment. Psychological Services, 16(4), 621-635.

  • 12/21/2023 12:43 PM | Anonymous

    Lori A Brotto, PhD - Department of Obstetrics and Gynaecology, University of British Columbia

    A lack of interest in sexual activity that creates personal distress and strains relationship satisfaction is the most common reason that women seek sex therapy. Described frequently by patients as “I’ve lost my libido,” or “It takes a long time for me to get sexually excited,” or “I would be content if we never had sex again!”, the presence of little or no desire for sex has received widespread attention from clinicians, researchers, and the lay public because of its complexity and seeming resistance to treatment. Female sexual interest/arousal disorder (SIAD) appears in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013). SIAD is based on polythetic criteria whereby women must endorse at least three of six of the following criteria in order to receive a diagnosis, with symptoms lasting at least six months (APA, 2013).

    1. lack of interest (or no interest) in sexual activity;
    2. reduced or absent erotic thoughts or fantasies;
    3. reduced level of initiating sex and/or responding to a partner’s sexual advances;
    4. reduced pleasure during sexual activity;
    5. lack of responsive sexual desire (i.e., desire that emerges with or after sexual arousal); and
    6. reduced genital and nongenital sexual sensations (i.e., arousal).

    The use of polythetic criteria means that a diagnosis of SIAD may involve different symptom expressions (Brotto et al., 2015). 

    Since SIAD has been in existence only since 2013, epidemiological studies on its prevalence have yet to be published, except for one online Flemish study that evaluated both spontaneous and responsive sexual desire (Hendrickx, Gijs, & Enzlin, 2014); however, there have been many large and representative studies focusing on the symptom of low or absent sexual desire. The third National Survey of Sexual Attitudes and Lifestyles (NATSAL-3) assessed 6777 women (who had a sexual partner in the last year) and found that 34.2% of women across ages endorsed low desire (Mitchell et al., 2013). Across the age cohorts, the highest prevalence was among women in the 55-64 year old category, and age was negatively associated with sexual desire. Between 15%-35% of women across the age categories reported having a discrepant level of sexual interest compared to their partners (Mitchell et al., 2013). In a study of Canadian middle-aged women, these rates of low desire were similar (Quinn-Nilas, Milhausen, McKay, & Holzapfel, 2018), and those with medical health conditions and poor overall health were more likely to report low desire in both studies. Low sexual desire is common among women affected by serious or life-threatening illnesses (e.g., cancer, cardio-vascular diseases). This is true for acute illnesses, and chronic conditions (e.g., thyroid disease, multiple sclerosis, arthritis) (McCabe et al., 2016). Women who have experienced childhood sexual abuse experience lower levels of sexual desire compared to non-abused women (Loeb et al., 2002; Stephenson, Hughan, & Meston, 2012).

    The Role of Attention in Women’s low Sexual Desire

    The Incentive Motivation Modelprovides a robust theory of sexual response that accounts for the roles of attention, memory, thoughts, and emotional reactions to determine whether a sexual stimulus might elicit sexual arousal in women. This theory illustrates how biological, psychological, and contextual factors interact to elicit sexual desire and arousal. It holds that sexual desire results from an interaction between a sexual response system and potent stimuli that activate the system. The incentive motivation model captures the experience of how sexual desire and arousal unfold for many women (regardless of whether they have sexual difficulties or not) because it highlights the important role of adequate sexual stimuli (i.e., internal or external cues that are perceived as sexually exciting) that trigger sexual motivation. This model is useful for identifying where a woman might experience a difficulty in sexual desire and/or arousal; for example, there is ample evidence that cognitive distraction during sex can be a significant precipitant of sexual difficulty (Nobre & Pinto-Gouveia, 2006) .This distraction, in turn, can impede the individual’s ability to notice sexual sensations in the body, and prevent desire from emerging following arousal (otherwise known as responsive sexual desire; Basson, 2001). Distraction, inattention, and/or judging of one’s unfolding sexual response have all been implicated in sexual desire and arousal difficulties in women (Chivers & Brotto, 2017).

    Evidence for the Benefits of Mindfulness in the Treatment of low Sexual Desire in Women

    With this theoretical understanding of the processes that elicit sexual arousal and desire, and evidence for mindfulness in a host of other domains of health, there is a solid rationale for the application of mindfulness-based approaches to improving desire and arousal difficulties in women.  In the early 2000s, mindfulness began to be applied to sexual dysfunction in women. Hypothesized mechanisms are that mindfulness training may allow women with low desire to become more aware of emerging physical changes during or in anticipation of sexual activity (e.g., genital vasocongestion, tingling), which may boost and maintain their experience of sexual arousal and desire, and further synching their physiological and psychological experience. There is also the putative role of helping an individual to recognize negative sex-related beliefs as simply “mental events”.

    One of the earliest documented empirical tests of mindfulness as an aid for sexual desire and arousal was in the context of gynecologic cancer survivors who experienced a profound sense of loss of sexual response following their treatment, and struggled with sexual desire, arousal, and satisfaction Over three monthly sessions in which a group of gynecologic cancer survivors with sexual dysfunction practiced mindfulness in and between sessions, there were significant increases in perceptions of physical as well as self-reported arousal, desire, satisfaction, and decreases in distress. In particular, some of the participants remarked that despite a change in arousal and responsivity following their cancer treatment, mindfulness allowed them to detect some residual arousal that they believed was gone, and that by using a combination of arousal enhancing techniques and mindfulness, they were now able to tune into their response and amplify it.

    Following this initial small study, several other studies of mindfulness as a treatment for low desire and associated sexual problems in women have been carried out. In one of the few large randomized clinical trials of mindfulness versus supportive sex education to women meeting diagnostic criteria for sexual interest/arousal disorder(Brotto et al., 2021) women attended 8 weekly groups where the facilitator guided mindfulness practice in session, followed by daily practice of mindfulness at home. Participants practiced mindfulness exercises formally in the first few sessions, and then progressively integrated mindfulness practice in progressively more sexual contexts such as while looking at oneself in a mirror, engaging in self-touch, non-sexual touching with a partner (e.g., sensate focus), and eventually during sex with a partner. Immediately after treatment, the mindfulness group led to significant improvements in sexual desire, sexual distress, relationship satisfaction, and rumination, and these improvements were retained at both the 6-month and 12-month follow-up time points.Moreover, participants self-reported a significant improvement to their quality of life and a general satisfaction with the treatment and the improvements they saw. By comparison, a psychoeducational comparison group that integrated elements of supportive-expressive therapy did not exhibit the magnitude of improvements in sexual distress, relationship satisfaction, or rumination that was seen in the mindfulness group; however, this group did show comparable improvements in sexual desire, suggesting that psychoeducational information, when delivered in a supportive-expressive environment, can be a very effective approach to improving sexual desire in women.

    What are the Mechanisms by Which Mindfulness Improves Sexual Desire in Women?

    Different underlying mechanisms have been proposed to account for the means by which mindfulness-based interventions improve suffering. For example, in his book Full Catastrophe Living, Kabat-Zinn postulated that there were seven specific attitudinal foundations by which mindfulness worked, and these included but were not limited to: Non-judging (reducing the tendency to categorize experiences as good or bad); Beginner’s Mind (attempting to experience repeated sensations as if for the first time); and Non-Striving (having no goal other than noticing one’s current experience). More contemporary interpretations of the mechanisms of mindfulness have been proposed (Brown et al., 2015), and include: that mindfulness cultivates the ability to notice that the primary aspects of one’s present experience are distinct; that mindfulness increases one’s ability to notice the automatic processes thus allowing one to make intentional decisions; and that mindfulness can foster meta-cognitive awareness.In contrast to the broader literature exploring mediators of mindfulness, very few studies have empirically evaluated the mediators of mindfulness-based therapy in the treatment of sexual dysfunction. Our team analyzed the mechanisms underlying the beneficial effects of mindfulness-based group sex therapy on desire and arousal symptoms in women, and we found thatimprovements in interoceptive awareness, self-compassion, self-criticism, depressive symptoms, and changes in mindfulness mediated the improvements in desire and distress (Brotto et al., 2023). Knowing that these were mediators of improvement after treatment of desire and arousal concerns means that a health care provider might recommend mindfulness for patients who have low desire and simultaneously have low levels of interoceptive awareness, self-compassion, and mindfulness, and higher levels of self-criticism and depressive symptoms. In addition to these identified mediators from quantitative analyses, another study analyzed qualitative feedback from patients to understand the mechanisms by which a mindfulness-based approach was effective for treating low desire in women. The authors found that shifts in patients’ locus or quality of attention during sex, their reduced avoidance behavior, their ability to disengage from negative thoughts, and their overall feelings of normalization when in a group with other women experiencing sexual difficulties were the mechanisms by which mindfulness improved low sexual desire (Meyers et al., 2023).

    If you want to read more about the science of mindfulness as it has been applied to sexual health, and women’s sexual desire in particular, you may find my 2018 book, Better Sex Through Mindfulness, to be of interest. And for those of you who may be interested in sharing the mindful sex treatment guide with your own clients, my 2022 workbook may also be of interest!

    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

    Basson, R. (2001). Using a different model for female sexual response to address women’s problematic low sexual desire. Journal of Sex & Marital Therapy, 27(5), 395-403.

    Brotto, L. A. (2022). The Better Sex Through Mindfulness Workbook: A Guide to Cultivating Desire. Vancouver, Canada: Greystone Publishing.

    Brotto, L. A. (2018). Better Sex Through Mindfulness: How women can cultivate desire. Vancouver, Canada: Greystone Publishing.

    Brotto, L. A., Graham, C. A., Paterson, L. Q., Yule, M. A., & Zucker, K. J. (2015). Women’s endorsement of different models of sexual functioning supports polythetic criteria of Female Sexual Interest/Arousal Disorder in DSM-5. Journal of Sexual Medicine, 12, 1978–1981.

    Brotto, L. A., Zdaniuk, B., Chivers, M. L., et al. (2021). A randomized trial comparing group mindfulness-based cognitive therapy with group supportive sex education and therapy for the treatment of female sexual interest/arousal disorder. Journal of Consulting and Clinical Psychology, 89(7), 626-639.

    Brotto, L. A., Zdaniuk, B., Chivers, M. L., et al. (2021). A randomized trial comparing group mindfulness-based cognitive therapy with group supportive sex education and therapy for the treatment of female sexual interest/arousal disorder. Journal of Consulting and Clinical Psychology, 89(7), 626-639.

    Brotto, L. A., Zdaniuk, B., Chivers, M. L., Jabs, F., Grabovac, A. D., & Lalumière, M. L. (2023). Mindfulness and sex education for sexual interest/arousal disorder: mediators and moderators of treatment outcome. The Journal of Sex Research60(4), 508-521.

    Brown, K. W., Creswell, J. D., & Ryan, R. M. (Eds.). (2015). Handbook of mindfulness: Theory, research, and practice. The Guilford Press.

    Chivers, M. L., & Brotto, L. A. (2017). Controversies of women’s sexual arousal and desire. European Psychologist, 22(1), 5-26.

    Hendrickx, L., Gijs, L., & Enzlin, P. (2014). Prevalence rates of sexual difficulties and associated distress in heterosexual men and women: Results from an Internet survey in Flanders. Journal of Sex Research, 51, 1–12.

    Loeb, T. B., Rivkin, I., Williams, J. K., Wyatt, G. E., Carmona, J. V., & Chin, D. (2002). Child sexual abuse: Associations with the sexual functioning of adolescents and adults. Annual Review of Sex Research, 13, 307–345.

    McCabe, M. P., Sharlip, I. D., Atalla, E., Balon, R., Fisher, A. D., Laumann, E. O., … Segraves, R. T. (2016). Definitions of sexual dysfunctions in women and men: A consensus statement from the Fourth International Consultation on Sexual Medicine 2015. Journal of Sexual Medicine, 13, 135–143.

    Meyers, M., Margraf, J., & Velten, J. (2023). Subjective effects and perceived mechanisms of change of cognitive behavioral and mindfulness-based online interventions for low sexual desire in women. Advance online publication.

    Mitchell, K. R., Mercer, C. H., Ploubidis, G. B., Jones, K. G., Datta, J., Field, N., … Wellings, K. (2013). Sexual function in Britain: Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet, 382, 1817–1829.

    Nobre, P., & Pinto-Gouveia, J. (2006). Dysfunctional sexual beliefs as vulnerability factors for sexual dysfunction. Journal of Sex Research, 43(1), 68-75.

    Quinn-Nilas, C., Milhausen, R. R., McKay, A., & Holzapfel, S. (2018). Prevalence and predictors of sexual problems among midlife Canadian adults: Results from a national survey. Journal of Sexual Medicine, 15, 873–879.

    Stephenson, K. R., Hughan, C. P., & Meston, C. M. (2012). Child Abuse & Neglect Childhood sexual abuse moderates the association between sexual functioning and sexual distress in women. Child Abuse & Neglect, 36, 180–189.

    Toates, F. (2009). An integrative theoretical framework for understanding sexual motivation, arousal, and behavior. Journal of Sex Research, 46, 168–193.

  • 11/29/2023 12:15 PM | Anonymous

    Cory F. Newman, PhD, ABPP - University of Pennsylvania, Perelman School of Medicine

    A common misconception about CBT is that the therapeutic relationship is not given sufficient attention; that it is taken for granted and not addressed as an important factor in therapy. A simple review of the literature in CBT demonstrates otherwise, in which the early, seminal works of A.T. Beck explicitly state that the methods of cognitive therapy (or CBT, as the two have become intertwined over the decades) require a caring, constructive, collaborative therapeutic relationship for the patient to benefit optimally from treatment (e.g., Beck, 1976; Beck, Rush, Shaw, & Emery, 1976). In 1980, Beck, along with Jeffrey Young, developed the Cognitive Therapy Scale (CTS: Young & Beck, 1980), which is perhaps the most widely used measure of competency in conducting generic, Beckian CBT. The CTS includes three scoring categories out of eleven that measure aspects of the therapeutic relationship, demonstrating the high priority that is placed on the relational competencies of the CBT therapist. In the ensuing years, many publications in the field of CBT offered empirical and clinical support for the importance of the therapeutic relationship in CBT, including methods for understanding, managing, and resolving difficulties in the alliance between therapist and patient (e.g., Safran & Segal, 1990; Gilbert & Leahy, 2007).

    When patients have significant, perhaps pervasive and chronic problems in their interpersonal lives, it is not uncommon for them to bring these difficulties into the therapeutic relationship (Safran & Segal, 1990). Sometimes this is manifested by a penchant for mistrusting the therapist, having unrealistic expectations for treatment, communicating in ways that are inadequate and/or aversive, and other such problems (see Newman, 1997, for extreme examples). Such scenarios pose special challenges for CBT therapists, who may come to realize that being pleasant, professional, attentive, and competent are necessary but insufficient conditions to earn optimal collaboration from some patients. Additionally, even when the patients do not necessarily manifest serious interpersonal dysfunction, they may have areas of psychological vulnerability (e.g., early maladaptive schemas, see Young, Klosko, & Weishaar, 2003) that can lead to alliance strains or ruptures when well-meaning therapists make a misstep (e.g., saying something that is invalidating). Therapists, as all humans, are fallible, and sometimes their errors can create stress and strain in the therapeutic relationship (e.g., forgetting something very important about a patient, to the patient’s dismay and chagrin). When any of these scenarios occur, it is a vitally important competency for the CBT therapist to be able to recognize the problem, conceptualize what is happening, take ownership of at least part of the process, maintain composure, empathy, and professionalism, and intervene to repair the strain or rupture in the therapeutic relationship (see Eubanks, 2022; Zilcha-Mano, Eubanks, Bloch-Elkouby, & Muran, 2021).

    The literature on problems in the therapeutic relationship has described two broad categories – withdrawal ruptures, and confrontation ruptures. Withdrawal ruptures refer to those scenarios in which the patient is disengaging from therapy, either within a session (e.g., giving perfunctory but inauthentic comments just to be polite) or outside a session (e.g., failing to show up for a session and then not returning the therapist’s messages). Withdrawal ruptures that occur in a session can sometimes be difficult to detect, as the patient often is not being explicit about their discomfort or displeasure with what is occurring in therapy. Therapists in this situation may ascertain that the energy in the session is low, and/or that progress in the session is sub-optimal, but they may not want to jump to the conclusion that the patient is silently unhappy with the process. Even when therapists ask their patients for feedback, there is a chance that the patient will simply state that things are fine, avoiding discussing their actual thoughts and feelings. Confrontation ruptures are more overt, in that they characteristically involve patients making comments or otherwise engaging in behaviors that are patently negative. Such comments may be described as complaining about or disagreeing with the methods of treatment, criticizing or blaming the therapist, and sometimes even expressing demands and threats. Here, the therapist’s main challenges are maintaining a professional demeanor, staying empathic, being able to listen, and then having the conceptual understanding and communication acumen to begin a process of trying to do constructive problem-solving with the patient, perhaps under duress.

    As mentioned above, therapists sometimes make mistakes that play a role in the alliance rupture, and this needs to be acknowledged. Nonetheless, there is evidence that alliance ruptures have been found to be more common in working with patients diagnosed with personality disorders than when treating patients without such diagnoses (Coutinho, Ribeiro, Sousa, & Safran, 2014). Interestingly, there is evidence that alliance ruptures with patients who have diagnosed personality disorders may present a positive opportunity for therapists to present the patients with a meaningful, corrective experience (in repairing the rupture) that allows their work to continue, perhaps with more of a sense of collaboration and optimism than was evident prior to the rupture, and with improved outcomes (Strauss et al., 2006; Cummings, Hayes, Newman, & Beck, 2011). With this in mind, therapists who are confronted with significant difficulties in their interactions with patients can rally themselves with the understanding that if they bring a high level of conceptual, relational, and technical skills to the situation they may be catalysts for significant therapeutic change. Recent studies of the phenomena and skills pertinent to repairing alliance ruptures suggest that the requisite competencies to manage these challenging situations can be taught (Eubanks, 2022; Muran, Safran, Eubanks, & Gorman, 2018), thus adding impetus to inclusion of this topic in supervised clinical practica and continuing education training.

    Clinical Examples

    The following are two, brief, representative examples of therapists recognizing and addressing alliance ruptures – a withdrawal rupture, followed by an example of a confrontation rupture. Each example is comprised of four parts: (1) situation, (2), patient’s responses, (3) therapist’s conceptualization of the patient’s responses, and (4) therapist’s responses.

    Withdrawal Rupture

    1. Situation: The patient, a young cisgender female diagnosed with a severe mood disorder, also shows signs of excessive eating restriction and a possible trauma history, neither of which she acknowledged at intake (or since). I (the therapist) delicately state that I would like to ask more about her eating habits as part of today’s session agenda, expressing worry about her gaunt appearance.
    2. Patient’s Responses: The patient looks downward, keeps her glance fixated there, and goes silent for a long period of time. She does not interact with me, even when I express concern and empathy, and even when I apologize for bringing up such a sensitive topic without advance notice.
    3. Therapist’s Conceptualization: The patient has stated earlier that she often feels that she has “no control” over her personal space and time in the face of demands and intrusions from her parents and her employer. It is also possible that she has experienced traumatic intrusions into her personal space that she has not yet discussed. She tries to maintain some semblance of control by circumscribing what she is willing (and not willing) to discuss in therapy. Apparently, I have just breached her boundary, and she is experiencing a negative affect shift, manifested by going mute and not making eye contact. This behavior may also reflect a self-protecting trauma response of trying to hide, though this is a topic we have not previously discussed. Now I have to facilitate giving her back a sense of control and safety.
    4. Therapist’s Responses: (At first remaining quiet, hoping that the patient will look up and see my sympathetic demeanor, but she does not, so I quietly, caringly state the following). “I can see you’re in some distress, and I’m concerned that my comments may have triggered you (long pause). I gather that asking about your eating is a very sensitive topic for you, and I probably should have realized that (long pause). If my comments and questions came across as a jarring invasion of your privacy, or maybe sounded like an accusation I sincerely apologize (long pause). You have a right to set the agenda for your own therapy, and I owe it to you to respect your agenda (short pause). I also think I owe it you to share with you my best clinical observations so you can have the most effective treatment plan, and that’s why I asked about your eating (short pause). I hope you will talk to me to let me know how you’re doing right now. I get bored listening to myself talk. I would much rather have a collaborative dialogue with you. I promise that I will be very respectful of what you have to say on this matter.”

    Confrontation Rupture

    1. Situation: The patient, a middle-aged cisgender male with a range of anxiety disorders and related IBS, notes that he succeeded in going hiking with some friends, overcoming his fear of heights and possibly not being able to find a bathroom when he might need it. I (the therapist) congratulate him, showing genuine enthusiasm for the patient’s accomplishment, and I wonder aloud how the patient might be able to generalize this success experience to attempt to face other previously avoided situations.
    2. Patient’s Responses: (Voice grows progressively more irritated in tone). So, you’re saying that what I did wasn’t enough? I should just do more, right? All this anxiety I’ve had my whole life, I should just fix it, right? That’s what you’re saying? You think it’s easy? Do I get a chance to just enjoy one small respite from my humiliation, or do I have to do more, and more, and more in this therapy? (Looking very tense in facial expression and sitting posture).
    3. Therapist’s Conceptualization: This patient has a long history of being humiliated for decades by his father for having anxiety and “not being a man.” Consequently, the patient – though he has friends and a successful career – has felt a deep sense of shame, often experiencing great anticipatory anxiety that his peers will discover his vulnerabilities and reject him. Currently, the patient does not hear my comments as supportive, respectful, and hopeful, but perhaps as patronizing, dismissive of the significance of what he has just done, and/or demanding more from him because he is not yet “good enough.” The patient’s fight-or-flight responses become heightened, as he experiences both anxiety and anger at this perceived insult and invalidation.
    4. Therapist’s Responses: (First, gathering myself in response to the patient’s unexpectedly angry comments, then proceeding in a manner that was meant to run totally counter-schematically to what the patient would have expected from his father, as Safran & Segal’s text would recommend). “I am genuinely happy for you. I also recognize that going hiking required a great deal of fortitude and belief in yourself. It’s a major deal, and I respect you for making this important step forward – probably at least 30,000 steps if we look at your Apple Watch. I would never, ever make light of anyone’s therapeutic achievements, and I never take for granted how difficult it can be to keep pushing beyond one’s comfort zone, again and again. You are way beyond “good enough.” And I am committed to supporting you.  

    Concluding Comment

    The clinical examples above are but “snippets” of what happens when a therapist identifies, conceptualizes, and responds therapeutically to an alliance rupture. It is not typically a quick or easy process, nor can it be expected to be linear (Lipner et al., 2023). The pathway forward can be dramatically positive, or less so, depending in part on how the patients perceive and respond to the therapist’s attempts to repair their rift. Regardless, the examples above provide a flavor of what is involved, how it fits very well within a CBT model, and how important it can be in preventing treatment drop-out and in promoting more positive therapeutic outcomes.

    Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.

    Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.

    Coutinho, J., Ribeiro, E., Sousa, I., & Safran, J. D. (2014). Comparing two methods of identifying alliance rupture events. Psychotherapy, 51, 434-442.

    Cummings, J. A., Hayes, A. M., Newman, C. F., & Beck, A. T. (2011). Navigating therapeutic alliance ruptures in cognitive therapy for avoidant and obsessive-compulsive personality disorders and comorbid Axis-I disorders. International Journal of Cognitive Therapy, 4, 397-414. DOI:10.1521/ijct.2011.4.4.397

    Eubanks, C. F. (2022). Rupture repair. Cognitive and Behavioral Practice, 29(3), 554-559.

    Gilbert, P., & Leahy, R. L. (Eds.) (2007). The therapeutic relationship in the cognitive-behavioral psychotherapies. Routledge/Taylor & Francis.

    Lipner, L. M., Liu, D., Cassel, S., Hunter, E., Eubanks, C. F., & Muran, J. C. (2023). V-episodes in the alliance: A single-case application of multiple methods to identify rupture repair. Psychotherapy, 60(1), 119-129.

    Muran, J. C., Safran, J. D., Eubanks, C. F., & Gorman, B. S. (2018). The effect of alliance-focused training on a cognitive-behavioral therapy for personality disorders. Journal of Consulting and Clinical Psychology, 86(4), 384-397. DOI:10.1037/ccp0000284

    Newman, C. F. (1997). Maintaining professionalism in the face of emotional abuse from clients. Cognitive and Behavioral Practice, 4(1), 1-29. DOI:10.1016/S1077-7229(97)80010-7

    Safran, J. D., & Segal, Z. V. (1990). Interpersonal process in cognitive therapy. Jason Aronson.

    Strauss, J.L., Hayes, A.M., Johnson, S.L., Newman, C.F., Barber, J.P., Brown, G.K., Laurenceau, J.P., & Beck, A.T. (2006). Early alliance, alliance ruptures, and symptom change in cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337-345. 

    Young, J. E., & Beck, A. T. (1980). The Cognitive Therapy Rating Scale. Unpublished manual. University of Pennsylvania, Philadelphia, PA.

    Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guideGuilford Press.

    Zilcha-Mano, S., Eubanks, C. F., Bloch-Elkouby, S., & Muran, C. J. (2021). Can we agree we just had a rupture? Patient-therapist congruence on ruptures and its effects on outcome in brief relational therapy vs. cognitive behavioral therapy. Journal of Counseling Psychology, 67(3), 315-325. Doi:10.1037/cou0000400.

  • 10/16/2023 9:00 AM | Anonymous

    Brian Thompson, PhD - The Portland Psychotherapy Clinic, Research, and Training Center

    Exposure therapy is a major success story with an extensive research base in the treatment of anxiety and obsessive-compulsive and related disorders (Norton & Price, 2007). Throughout the decades since exposure was first demonstrated in Mary Cover Jones’ pioneering work (Kazdin, 1978), there have been several models developed to better understand how exposure works. For over 30 years, the most dominant model of exposure—to a degree that it is almost synonymous with exposure—has been the emotional processing theory (EPT; Foa & Kozak, 1986). According to EPT, exposure to the feared stimulus activates response and meaning elements of an emotion network and allows for the incorporation of newer corrective information through decreases in fear across exposures—what is called between-session habituation (Rupp, Doebler, Ehring, & Vossbeck‐Elsebusch, 2017). Newer research, however, has found that fear reduction is a poor predictor of whether people benefit from exposure therapy (Baker et al, 2010; Kircanski, et al, 2012). Consequently, EPT does not appear to fit with contemporary exposure research (Craske et al., 2008).

    Acceptance and commitment therapy (ACT) is a newer cognitive behavioral treatment that emphasizes increasing psychological flexibility—taking action towards what is important to us even when in contact with uncomfortable thoughts, feelings, and bodily sensations—as a target of treatment. ACT has been described as an “exposure-based therapy” because it encourages people to remain in contact with difficult experiences they may otherwise avoid (Luoma, Hayes, & Walser, 2017). As it explicitly deemphasizes symptom reduction, in contrast to EPT, viewing a focus on symptom reduction as fostering a “fear of fear,” ACT theory is one alternative model for guiding exposure therapy that is consistent with new research. Additionally, ACT is a more process-based treatment in its focus on broader transdiagnostic processes of change compared to other cognitive behavioral evidence-based treatments that are more protocol-driven, (Hayes & Hofmann, 2021).

    Within ACT, psychological flexibility has been described as both a single process, and it has also been broken down into smaller processes. The ACT hexaflex is the most common grouping of ACT processes that comprise psychological flexibility:

    • Contact with the present moment
    • Willingness (or acceptance) to stay in contact with discomfort (e.g., emotions; bodily sensations).
    • Defusion, or the ability to be aware of thoughts with some distance without necessarily believing in their literal reality
    • Self-as-context, or the ability to flexibly shift between perspectives rather than fusing with a particular self-concept or perspective
    • Values, meaningful life directions in which we may choose to orient behavior
    • Committed action, or taking action based on our values

    Exposure appears to strengthen psychological flexibility whether delivered in an ACT context or not (Thompson, Twohig, & Luoma, 2021; Twohig et al., 2018), and the ACT process of acceptance or willingness appears to be a better predictor of change in exposure therapy than habituation (Reid et al., 2017). Overall, psychological flexibility appears to be an important transdiagnostic process of change even in other non-ACT treatments (e.g., Arch et al., 2012).

    When compared against exposure therapy based on EPT, ACT-informed exposure performs about as well on primary outcomes (Arch et al., 2012; Craske, Niles, et al., 2014) Twohig et al., 2018). Rates of relapse in ACT-informed exposure are also comparable to those of traditional exposure (Arch et al., 2012; Twohig et al., 2018). There is some evidence that clients in ACT-informed exposure demonstrate additional improvements in symptom severity and psychological flexibility between treatment completion and follow-up, whereas those in traditional exposure simply maintain gains at follow-up (Arch et al., 2012; Craske, Niles, et al., 2014).

    In our recently published pandemic project, a therapist guide on using ACT-informed exposure, ACT-Informed Exposure for Anxiety: Creating, Effective, Innovative, Values-Based Exposures Using Acceptance and Commitment Therapy, (Thompson, Pilecki, & Chan, 2023), my coauthors and I make a case for how the ACT psychological flexibility model has advantages over traditional exposure based on EPT in offering an expanded nomenclature for understanding and targeting processes common to exposure therapy. For example, acceptance of discomfort during exposure is important in facilitating new learning in any type of exposure. When clients engage in covert avoidance behavior such as rushing through an exposure exercise or tensing up, we know these behaviors can interfere with learning because, if clients are unable to be present and practice acceptance with feared stimuli, this behavior may reinforce anxiety and avoidance (e.g., Benito et al., 2018; Ong et al., 2022). ACT has a variety of exercises and metaphors for orienting clients to this process (e.g., Hayes, Strosahl, & Wilson, 2012; Eifert & Forsyth, 2005), offering the therapist and client a shared way of speaking about acceptance or willingness during exposure. In exposure approaches based on EPT, by contrast, acceptance tends to be more implicit (Moscovitch, Antony, & Swinson, 2009).

    The research on ACT-informed exposure is still nascent—especially compared to exposure based on EPT. However, ACT-informed exposure appears promising and is consistent with emergent data on mechanisms of change during exposure. It offers a flexible, process-based alternative to traditional exposure.

    Arch, J.J., Eifert, G.H., Davis, C., Plumb Vilardaga, J.C., Rose, R.D., & Craske, M.G. (2012). Randomized clinical trial of cognitive behavioral therapy (CBT) versus acceptance and commitment therapy (ACT) for mixed anxiety disorders. Journal of Consulting and Clinical Psychology, 80, 750-765.

    Baker, A., Mystkowski, J., Culver, N., Yi, R., Mortazavi, A., & Craske, M.G. (2010). Does habituation matter? Emotional processing theory and exposure therapy for acrophobia. Behaviour Research and Therapy48(11), 1139-1143.

    Benito, K.G., Machan, J., Freeman, J.B., Garcia, A.M., Walther, M., Frank, H., Wellen, B., Stewart, E., Edmunds, J., Kemp, J., Sapyta, J., & Franklin, M. (2018). Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. Journal of Consulting and Clinical Psychology, 86(7), 615–630.

    Craske, M.G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy46, 5–27.

    Craske, M.G., Niles, A.N., Burklund, L. J., Wolitzky-Taylor, K.B., Vilardaga, J.C.P., Arch, J.J., ... & Lieberman, M.D. (2014). Randomized controlled trial of cognitive behavioral therapy and acceptance and commitment therapy for social phobia: outcomes and moderators. Journal of Consulting and Clinical psychology82(6), 1034-1048.

    Eifert, G.H., & Forsyth, J.P (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. Oakland, CA: New Harbinger.

    Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99, 20–35.

    Hayes, S.C., & Hofmann, S.G. (2021). “Third‐wave” cognitive and behavioral therapies and the emergence of a process‐based approach to intervention in psychiatry. World Psychiatry20(3), 363-375.

    Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.

    Kazdin, A.E. (1978). History of behavior modification: Experimental foundations of contemporary research. Baltimore: University Park Press.

    Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A.S., Mystkowski, J.L., Yi, R., & Craske, M.G. (2012). Challenges to the traditional exposure paradigm: Variability in exposure therapy for contamination fears. Journal of Behavior Therapy and Experimental Psychiatry, 43, 745-751.

    Luoma, J.B., Hayes, S.C., & Walser, R.D. (2017). Learning ACT: An acceptance & commitment therapy skills training manual for therapists (2nd ed.). Oakland, CA: Context Press.

    Norton, P.J. & Price, E.C. (2007). A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. The Journal of Nervous and Mental Disease, 195(6), 521-531.

    Moscovitch, D.A., Antony, M.M., & Swinson, R.P. (2009). Exposure-based treatments for anxiety disorders: Theory and process. In M. M. Antony & M. B. Stein (Eds.), Oxford handbook of anxiety and related disorders (pp. 461–475). Oxford University Press.

    Ong, C.W., Petersen, J.M., Terry, C.L., Krafft, J., Barney, J.L., Abramowitz, J.S., & Twohig, M.P. (2022). The “how” of exposures: Examining the relationship between exposure parameters and outcomes in obsessive-compulsive disorder. Journal of Contextual Behavioral Science24, 87-95.

    Reid, A.M., Garner, L.E., Van Kirk, N., Gironda, C., Krompinger, J.W., Brennan, B.P.,…Elias, J.A. (2017). How willing are you? Willingness as a predictor of change during treatment of obsessive-compulsive disorder. Depression and Anxiety, 34, 1057-1064.

    Rupp, C., Doebler, P., Ehring, T., & Vossbeck‐Elsebusch, A.N. (2017). Emotional processing theory put to test: A meta‐analysis on the association between process and outcome measures in exposure therapy. Clinical Psychology & Psychotherapy24(3), 697-711.

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    Thompson, B.L., Pilecki, B.C., & Chan, J.C. (2023). ACT-informed exposure for anxiety: Creating, effective, innovative, values-based exposures using acceptance and commitment therapy. Oakland, CA: Context Press.

    Thompson, B.L., Twohig, M.P., & Luoma, J.B. (2021). Psychological flexibility as shared process of change in acceptance and commitment therapy and exposure and response prevention for obsessive-compulsive disorder: A single case design study. Behavior Therapy52(2), 286-297.

    Twohig, M.P., Abramowitz, J.S., Smith, B.M., Fabricant, L.E., Jacoby, R.J, Morrison, K.L., Lederman, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour Research and Therapy, 108, 1-9.

  • 10/08/2023 4:31 PM | Anonymous

    Lucas S. LaFreniere, PhD - Skidmore College

    In part 1 of this primer, we took a deep dive into explaining savoring’s nature—its processes (noticing, intensifying, and prolonging) and its components (targets, emotions, and attention). But how do we train the actual practice of savoring? Understanding is one thing, but doing is quite another. Here in part 2, we address doing the doing. Importantly, note that all the techniques we’ll cover are derived from the basic research, theory support, and clinical trials presented in part 1 (e.g., Craske et al., 2019; Kiken et al., 2017; LaFreniere & Newman, 2023b; Sin & Lyubomirsky, 2009; Smith & Bryant, 2017; Wilson & MacNamara, 2021; etc.).

    General Procedures: Identify and Immerse

    No matter which exercise we use, savoring practices generally involve two core procedures: 1) identifying target factors that elicit positive emotion and 2) immersing oneself in the good feelings. When we identify, we note the things we like about the savoring target and the positive emotions it brings up. The client recognizes and states the aspects of an experience that they find enjoyable. When identifying, it can be helpful to have clients briefly name what they like and feel, out loud. For example, I once had a client with depression who said he liked leopards. In the service of savoring, we watched an online clip of a nature documentary on leopards together. As he watched, I had him state all the things that brought him even the most mild pleasantness from it—the leopard’s graceful motion, their powerful speed, the look of their facial patterning, etc. You could physically see his mood shift brighter with each new factor he named.

    As clients name their likings like this, you can encourage greater enjoyment with both your verbal and non-verbal responses. If you also like the things they like, say it—with a bit of reinforcing gusto if you can. Try to enthuse about their likings alongside them. Invite them into riffing on what’s great about the target. If you can muster it, add a little “happy energy” too—smiling, nodding, putting passion in your voice. Modeling savoring in this “monkey see, monkey do” type of way can be a powerful instructive tool—one that goes deeper than just words. Yet note that clients should only identify or name out loud if it doesn’t interfere with their experience. For some, identifying and naming during savoring may distract, interrupt, or pull them “into their heads” thinking, thinking, thinking. Remember, savoring is mostly about feeling. Regardless, when clients first start learning to savor, it’s nearly always beneficial for them to consciously key into what they like about an experience. Over time, identifying allows people to discover what they actually enjoy, rather than what they just think they enjoy or have been told they should enjoy. Moreover, as we spend more time identifying, we tend to find more parts of life to like. As poet Ross Gay (2019)writes in his Book of Delights, “The more stuff you love, the happier you will be.”

    Identifying is just the start of savoring though—a way to get the motor running. The truest aspect of savoring is immersing. When we immerse, we attend fully to the joyful feeling, engaging with the positive emotion as deeply as we can for as long as we can. This is the actual work of noticing, intensifying, and prolonging good feelings. There are many ways we can guide the client’s immersion to maximize its benefits. Take intensification for example. While the client is immersing, we can ask them to “grow the glow”—to attempt to increase the emotion in whatever way works for them. You can guide them with statements like, “Pay deeper attention to the parts you like about this... Can you boost the good feeling?... Can you imagine it as a flame inside you?... Can you fan it bigger, or even douse it with gasoline?”, etc.

    Outward expression can enhance this effort. Clients should be encouraged to allow themselves to smile, move their bodies, gesture with their arms or hands, or express in any other way they’d like (Montillaro & Dukes, 2018). When a person is really happy, it may even spark the “joy jumps” natural to many mammals (if you need a smile today, take a peak that this study: Kaufmann et al., 2022). Joy jumps are a big ask, but I do stress encouraging clients to allow themselves to smile. Even just a slight, peaceful smile is enough. Smiling can help us better access positive feelings, as well as enter our enjoyment more “bravely.” Often we’ve been punished, mocked, or otherwise “shut down” for expressing positive emotion in the past—others saying it’s “too much,” it “bugs me,” it’s “cheesy.” I encourage clients to “embrace the cheese” of opening up to a totally liberated joy. Smiling helps this work along, facilitating an unashamed, unflinching sort of delight.

    After attempts to intensify, you can direct clients to hold on to their feelings as long as they can (prolonging). They can rehearse the aspects of the target they like. They can also find new likings to extend their enjoyment, reflecting further on the experience. As a person continues savoring, they’ll lose attention from time to time—their “to-do” list will barge in, a fear will crop up, a needy device will buzz them out of focus, etc. That’s not only okay, but expected. If we lose our attention to positive emotion while savoring, we just gently redirect back to it. No need to beat ourselves up.

    Okay, let’s pull this all together. In general, a savoring exercise will include choosing some type of target experience to savor, acknowledging its enjoyable elements, and engaging with the positive emotions. Identify and immerse—highlight the highlights and feel the feelings. Note that you can do identifying and immersing in any order. Either can come first, although starting with identifying may suit beginners best. I suspect great savorers actually tend to move back and forth between identifying and immersing seamlessly over time. Regardless of sequence, there are countless ways you can conduct savoring practices in session. Have the client bring a food, choose an enjoyable song, watch a favorite video clip online, view photos of beloved people or pets on their phone, or think of their own target. You could present the savoring practice as a guided meditation akin to mindfulness, or dress it up in some other way. In any case, once they’ve practiced savoring in session, have them schedule specific savoring exercises in their lives outside of session. We want them to not only become accustomed to actually savoring in real life, but to also think of turning to it when useful, automatically. You can get very structured with it if you’d like, planning, charting, and rating savoring activities like in behavioral activation (Dimidjian et al., 2008). Regardless, repeated practice is key. Savoring is a skill that we’re training, and we hone a skill by practicing it over and over.

    Savoring Exercises Across a Range of Difficulties

    Identifying and immersing is a basic blueprint for savoring training. You can take it and get endlessly creative with it, varying targets, contexts, timeframes, and tasks. Yet to help you get started, let’s cover a few specific exercises. Now, savoring practices can be easier or harder based on many different factors—the complexity of the exercise, the situational context (how stressful, rewarding, distracting, etc.), the client’s state of mind, level of savoring experience, level of emotional awareness, etc. Beginning strategies tend to lean more on identifying, are more concrete, and tend to be practiced in stress-free contexts. Harder strategies lean more on immersing, are more abstract or complicated, and may be practiced in high stress contexts. It can be helpful to know (and assign) savoring practices that cover the full range of possible difficulties. You can tailor the training to the client, ratcheting up the challenge as they improve. Here are a variety of practices from easier to more difficult.

    Level 1: Easier Strategies

    • Tagging: Tagging is consciously acknowledging that an experience is good as it occurs, in-the-moment. When a client notices their current moment is enjoyable or positive, they say or think to themselves, “This moment is good.” As they catch the sunshine walking from the car to the store... as they take their first sip of coffee after lunch... as they pause to stretch during evening chores—“This moment is good.”  It’s like clipping a “tag” of good onto the moment (or, in social media lingo, “tagging” the experience like an online post). We’re getting out our mental label maker and slapping a GOOD label on the here-and-now. As these labels pile up, it may re-train our attention toward positive parts of our experience, as well as give life a certain overall sheen. Tagging may be the least demanding practice, but it will still take some intention and awareness.
    • Listing Likings: With listing likings, clients list all the things they like about an experience. We can list likings about literally anything—experiences, people, situations, foods, tasks, etc. This is simply a direct method for training identifying. You can start by asking clients, “What’s one of your favorite activities?” Then have them list everything they like about it. After, clients can savor whatever positive emotions result from noticing these likings.
    • Savoring in Session: We’ve already covered this one above, but it’s worth giving it some screentime here. In session you can guide the client in a sort of savoring meditation: They are led through savoring positive emotions from any chosen target. Start them with identifying, then talk them through immersing. Debrief afterward, discussing their experience. I highly suggest that the client chooses their own target (i.e., the song, the food, the video, etc.). Again, I also recommend that you model savoring for the client. Show them how it’s done by identifying along with them, or even do it before they do. List your own likings, describe your own process, and—despite all your very serious degrees and distinctions—smile!
    • Two-Passes Savoring: It can sometimes be helpful to savor the same target twice, first listing likings, then feeling feelings. On the first pass, the client simply identifies. On the second pass, they engage with the positive emotions that arise from attending to their likings. For example, you can have a client choose an enjoyable song for you both to listen to together. On the first play through, they state everything they like about it. Then, on the second play through, they feel, amplify, and extend the positive emotions they get from attending to the things they like about the song. Breaking it down in this two-step way not only helps beginners, but also those who keep finding “just feeling it” to be difficult.
    • Best Moments Time Machine: If you want to really get the ball rolling, have the client access their most potently-joyful memories. The stronger the positive feeling, the easier it is to savor. Have the client either recall or journal about the happiest or most contented moments of their life. Actively discuss what those moments were like for them. What made it enjoyable? What did it feel like? Draw their attention to the elements that led them to feel positive emotions, like loved, proud, cheerful, etc. After they describe it, have them try to truly experience the feelings while they remember it—and dwell in them over time. This is a robust reminiscing practice that can go a long way, starting with a bang before trying less punchy targets.
    • Enjoyment Monitoring: With enjoyment monitoring, clients track and rate their enjoyable moments (on paper, a phone app, computer, etc.). Either during the moment or at some scheduled time of day, they write down what the moment was, rate how much they enjoyed it from 0 to 10, and—if enjoyment was a 5 or greater—list likings for that moment. Clinicians who are well-versed with behavioral activation will be very familiar with this tried-and-true method. It may reveal some strong activation activities for the client, which can also be savoring targets.

    Level 2 Moderate Strategies

    • Randomized Savoring: Clients can stretch their savoring skills by being cued to savor good aspects of random moments—savoring at unplanned, unexpected times. You can facilitate this by setting up repeating, randomly-timed smartphone reminders. These reminders can nudge clients to find something good about their current moment—anything at all—and savor it. There are a variety of smartphone apps for random prompting, such as Yapp Reminders on iOS/iPhone or Randomly RemindMe on Android. The client could also set up a simple series of alarms or timers. Regardless, the idea here is to pause when prompted, identify a liking or two, and immerse right where they are.
    • Daily Savoring Meditation: Clients can also commit to savoring at specific, planned times. Each day they can conduct their own savoring meditation at a time that works well for them. Reminiscing (savoring a memory) often works well for this, given that it’s possible to do at nearly any moment. To help, you can record a guided audio meditation for them to take with them. Note that it’s best for them to eventually be able to savor on their own though, unguided.
    • Scheduled Savoring Activities: Similarly, clients can plan fun activities to intentionally savor between sessions. This allows them to get committed practice with actually savoring in-the-moment. Later on that day (e.g., before bed), they can practice reminiscing by savoring the memory of the activity.
    • Relational (Shared) Savoring: Relational savoring is when a person savors an experience with another person, often discussing what they like and feel. You can teach/assign your client to purposefully enthuse about a shared experience with another person. They can plan some activity, then aim to openly express likings and feelings of enjoyment with someone close. Think concerts, movies, meals, art shows, hikes, dog parks, etc. As they do this, it’s key to help them hold back from criticizing the moment. They should try to inhibit any urges to qualify or dampen the goodness of it. Many of us have been socialized to connect with others through complaining, mocking, cynicism, or other forms of noting negative points. It’s easy to slip into this “social sourpussery,” and—yes—it does have a time and a place. Yet in relational savoring, we’re intentionally taking an opposite tack: “Rant” about the goodness you can find, and do it together.
    • Savored Memory Recording: In the spirit of reminiscing, clients can keep an ongoing record of good experiences. Here they simply write down positive memories in a notebook, electronic document, or phone app, similar to a gratitude journal. It’s best to also purposefully savor these memories during or after recording them. Clients can recall the moments as vividly as possible, then juice out all the glee they can get from them.
    • Savoring Visualizations: You can equip clients with mental images and imaginal metaphors to help deepen a savoring meditation. While guiding, ask clients to imagine their positive emotion as a flame or a warm glow inside them. Invite them to “grow the glow,” asking if they can increase its size or intensity. Encourage them to keep the flame going over time if they can. If clients have trouble with intensifying or prolonging, try turning to visualization.
    • Abundance Basket: I designed the “abundance basket” exercise to help clients connect with the amount of good, savorable things in their lives. Essentially, they imagine filling increasingly larger vessels with all the enjoyable things their minds can conjure up. To do this, first invite clients to close their eyes. Then have them imagine a basket in front of them. Ask them to imagine filling up the basket with things they enjoy, one at a time. These things may not only be items (foods, hobby objects, books, etc.), but also people, pets, or representations of more abstract things (e.g., to symbolize an activity, put in some related trinket; to symbolize personal free time, put in a clock with wings; etc.). Do this until the basket is as full as they can get it. Once its filled (or they think of items too large to fit in the basket), guide them to imagine a larger vessel to fill—a storage chest, a Uhaul, a warehouse. Following this pattern, they should imagine more and more, bigger and bigger things they love. After some time has passed, guide them to reflect on the sheer volume of all the enjoyable things in their life—savoring as much as they can.
      Here are some tips: If you’d like, you can have them state the things they select out loud. Alternatively (or in addition), you can ask about these things afterward, as well as discuss the client’s experience with the activity. Your goal here is to help them get in touch with how much goodness there is out there for them to savor. They can then practice savoring with this mountain of targets. Note that the “basket fillers” should be things that are actually a part of their life (including people, pets, places, etc.)—not wishes, wants, or fantasies. Also make sure to use smaller vessels first, then move to larger vessels only when the smaller ones fill. A sense of “overflow” is the heart of the exercise. Lastly, feel free to turn this into a journaling activity. They write down a record or list of their “abundance,” then savor it. As for the imaginal exercise though, here’s a script you can use to get started:
      • “If you’re willing, I invite you to close your eyes... With your eyes closed, imagine a basket in front of you... We’re going to fill up this basket in our minds. I’d like you to imagine good things—things that you enjoy—and place them in the basket, one by one... Try to fill it with things that bring you positive emotion in your life, that you love.... Keep placing new things in your basket until it spills over... Now that your basket doesn’t have enough space to hold it all, imagine a bigger vessel—a box, a storage chest, a Uhaul, a warehouse.... Keep finding good things to place in your vessel... You can imagine more and more things... and bigger and bigger things to put in the bigger vessels... [You can guide clients through each larger vessel, which they can describe to you, following the pattern above. Once you find a good stopping point, pause for a moment and say the following:] Now, take a moment to look out on all the abundance of what is good in life—all these things you enjoy... Really feel the positive emotion you get from all these things... Savor it all as fully as you can, holding on to those good feelings.
      • Savoring Survival Kit: Along the lines of the abundance basket, you can have clients actually put together a small collection of items to savor on demand—their favorite chocolate, candies, or snacks, photographs, souvenirs of vacations or places, etc. They can pull this out any time they want to savor in a pinch.

    Level 3 Challenging Strategies

    I want to take a different approach to addressing difficult strategies. Training strategies on the harder end require special care and finesse. Savoring is more challenging when the client is in a tough situation, a state of emotional distress, or feeling resistant to enjoyment. There’s a fine line to walk at these times, validating their pain while still encouraging savoring for their own good. Life can be tough, no doubt about it. Self-protection and prevention of harm can crowd out life’s goodness for all of us. Yet even at these times, life’s positive points may harbor some benefits. Clients with anxiety, trauma, and depression often strongly prioritize managing and bracing for possible negative events. This priority can far exceed that of enjoying present-moment rewards. When our minds and bodies are telling us we should be preparing for the worst, sitting with positive emotion can feel quite vulnerable. Within this context, savoring can actually function like a sort of exposure therapy. Thus, we can conduct difficult savoring strategies much like exposure, bringing to it a similar sensitivity, mindset, and process. Fortunately, this vulnerable form of savoring does appear to both lower symptoms and improve happiness (LaFreniere & Newman, 2023b). For more on this point, you can refer to LaFreniere & Newman, 2023a. Still, we can’t always expect favorable returns. It will take practice and intuition to know when vulnerable savoring is appropriate, warranted, and beneficial. Yet if you can key in to these opportune moments, there may be much to be gained.

    Okay, yes, but what are the strategies? Well, they’re essentially any of the savoring techniques above, just completed under circumstances the client perceives to be negative. These circumstances may be unsavory external situations or aversive internal states. Regardless, clients are led to try out a savoring practice while irritated, sad, anxious, ruminating, stressed out, or in any other sort of funk. For example, savoring amidst a train of worry has been shown to be helpful, cutting off the worry’s momentum. In one experiment, savoring immediately after a worry induction in those with Generalized Anxiety Disorder not only dropped their worry and anxiety, but also sparked a positive emotional state (Rosen & LaFreniere, 2023). Even so, be careful not to dismiss or discount the client’s negative feelings or situation. Clients may be able to savor good elements of a generally bad experience. Yet we don’t want to send an invalidating message that the overall experience isn’t bad, or—worse—that it doesn’t even exist. When in doubt, remember that you can conduct savoring exercises just like you would exposure therapy. As savoring melts away whatever woes it can, it may become easier and stronger, catching fire over time.

    Continued in Part 3: Challenges, Pitfalls, and Solutions

    There you have it! A smorgasbord of savoring strategies, plus a few tips and tricks. To continue on and read about common challenges in savoring work—as well as their solutions— stay tuned for part 3 of this primer. When published, you can follow the link below to that article. - COMING SOON!

    Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology, 87(5), 457-471.

    Dimidjian, S., Martell, C. R., Addis, M. E., Herman-Dunn, R., & Barlow, D. H. (2008). Behavioral activation for depression. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A step-by-step treatment manual (4th ed., pp. 328-364). Guilford Press.

    Gay, R. (2019). The Book of Delights. Algonquin Books of Chapel Hill.

    Kaufmann, L. V., Brecht, M., & Ishiyama, S. (2022). Tickle contagion in the rat somatosensory cortex. iScience, 25(12), 105718.

    Kiken, L. G., Lundberg, K. B., & Fredrickson, B. L. (2017). Being present and enjoying it: Dispositional mindfulness and savoring the moment are distinct, interactive predictors of positive emotions and psychological health. Mindfulness, 8(5), 1280-1290.

    LaFreniere, L. S., & Newman, M. G. (2023a). Reducing contrast avoidance in GAD by savoring positive emotions: Outcome and mediation in a randomized controlled trial. Journal of Anxiety Disorders, 93, 102659.

    LaFreniere, L. S., & Newman, M. G. (2023b). Upregulating positive emotion in generalized anxiety disorder: A randomized controlled trial of the SkillJoy ecological momentary intervention. Journal of Consulting and Clinical Psychology, 91(6), 381-387.

    Montillaro, M., & Dukes, D. (2018). Jumping for joy: The importance of the body and of dynamics in the expression and recognition of positive emotions. Frontiers in Psychology, 9.

    Rosen, F. N., & LaFreniere, L. S. (2023). Savoring, worry, and positive emotion duration in generalized anxiety disorder: Assessment and interventional experiment. Journal of Anxiety Disorders, 97, 102724.

    Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology: In Session, 65(5), 467-487.

    Smith, J. L., & Bryant, F. B. (2017). Savoring and well-being: Mapping the cognitive-emotional terrain of the happy mind. In M. D. Robinson & M. Eid (Eds.), The happy mind: Cognitive contributions to well-being (pp. 139-156). Springer.

    Wilson, K. A., & MacNamara, A. (2021). Savor the moment: Willful increase in positive emotion and the persistence of this effect across time. Psychophysiology, 58(3), e13754.

  • 08/25/2023 7:59 AM | Anonymous

    Lucas S. LaFreniere, PhD - Skidmore College

    Can you recall a time you enjoyed something to the fullest? Seriously—a time you wholeheartedly relished an experience, delighting in it as deeply and as long as you could? In essence, I’m asking about enjoying on purpose. Positive emotions can be fleeting if they’re not captured. We often accept them passively as they come to us, yet fail to actively seek them out, embrace them, and hold on. Savoring practices offer us ways to do this embracing—to deliberately engage with joy and make it last. This active approach to good feelings has clinical utility for both reducing psychopathology and increasing happiness. In studies, savoring has reduced clinical levels of worry, anxiety, and depression symptoms (Bolier et al., 2013; Craske et al., 2019; Doorley & Kashdan, 2021; Garland et al., 2010; Gloria & Steinhardt, 2016; LaFreniere & Newman, 2023a, 2023b; Sin & Lyubomirsky, 2009), lessened attentional bias to negative information (Smith et al., 2006), and built resilience to and recovery from adversity (Catalino et al., 2014; Fredrickson et al., 2000). At the same time, savoring increases the frequency and intensity of positive emotions (Kiken et al., 2017; LaFreniere & Newman, 2023b; Quoidbach et al., 2010; Rosen & LaFreniere, 2023; Smith & Bryant, 2017; Wilson & MacNamara, 2021), while magnifying the beneficial effects of positive events on mood and cognition (Corman et al., 2020; Jose et al., 2012; Wilson & MacNamara, 2021). In short, if we get better at feeling our good feelings, we can feel good. Although a variety of empirical studies now support the use of savoring in treatment (e.g., Craske et al., 2019; LaFreniere & Newman, 2023b; Rosen & LaFreniere, 2023), few explain how to actually put it into practice. This three-part primer aims to teach readers how to implement savoring techniques for improving mental health. We’ll cover core concepts and psychoeducation here in part 1, move on to specific procedures and exercises  in part 2, and finish with common challenges and solutions in part 3. Of course, please do refer to scientific studies on the clinical mechanisms and outcomes of savoring (this is a good start: LaFreniere & Newman, 2023a). Yet here we’ll face the feet-on-the-ground, hands-in-the-dirt work of actually training purposeful enjoyment.

    The Key Concepts of Savoring

    Training clients in savoring skills starts with psychoeducation. As with any quality psychoed., clearly defining our skill is a good first step. Savoring is intentionally attending to, amplifying, and extending the duration of positive emotions. The big idea here is that savoring maximizes engagement with positive emotions—both in their intensity and their timespan. It’s like plunging a big brazen spoon into the moment, then taking a slow, enrapt, delighted mouthful. To get more technical, savoring includes three processes: Noticing, intensifying, and prolonging. First, when savoring, we (1) notice our positive emotions. We consciously feel them when they arise, turning our mind to them on purpose. Since we can’t physically “show” clients how to notice, it helps to use some metaphorical language. ‘Noticing’ language can include words like bask, soak, engage, immerse, experience it fully, touch, absorb, and inhabit. Second, when we savor, we also try to (2) intensify the strength of our positive emotions. ‘Intensify’ can be communicated with phrases like fan the flame, whip up, juice, swell, amplify, boost, empower, and rally. Lastly, when we savor, we also (3) prolong positive emotions for as long as we can. We hold on to them, dwell on them, sustain them, draw them out, perpetuate them, and keep them going. So savoring is noticing, intensifying, and prolonging positive emotions. Both clinicians and clients should hold all three of these processes in mind, encouraging or attempting each one.

    Now, a crucial element of savoring is that it is purposeful. When we savor, we make a deliberate, conscious choice to enjoy. It’s enjoyment not as a reflex, but as an act of intentional mission. Often people have lived their lives counting on external events, milestones, or winfalls to “bestow” their happiness upon them (“when I find the right partner... when I get this stress out of my life... when I finally retire...”). In savoring, we’re not waiting on situational changes to “make us happy” in a passive, automatic way. Our goal for clients is to actively grasp the good feelings already available to them. Here are some examples: A) Purposefully focusing your attention on how happy you feel when you’re out with friends; B) Dwelling on the joy you experience while listening to a song you love; C) When you succeed at the office, intentionally amping up your celebratory feelings and keeping them going (“Drinks after work anyone?”).

    Components of Savoring: Targets, Emotions, and Attention

    Any act of savoring has three components: A target, an emotion, and our attention. Notice that in each of the examples above, the positive emotions arise in response to something—time with friends, music, and work success. Each of these experiences is a savoring target. A savoring target is anything that elicits positive emotions. Targets can include stimuli we sense with our five or more senses (e.g., the fuzziness of a blanket, the taste of a brownie, the sound of a chime), as well as thoughts, memories, objects, activities, or people. Honestly, a target can be any feel-good experience or thing. If it leads you to experience positive emotions, it can be a savoring target. Positive emotions are simply feelings we experience as pleasant, represented in body and mind. They include joy, amusement, interest, love, cheerfulness, empowerment, wonder, excitement, awe—any good feeling. The act of savoring is actually drawing our attention to these positive emotions—noticing them, leaning into them, and dwelling on them. Targets can drum up positive emotions without attempting to savor them, of course. Yet research shows that deliberate savoring practices amplify the strength, length, and benefits of these emotions (e.g., Wilson & MacNamara, 2021). We’re also more likely to notice good feelings if we’re trying to notice them. Thus, attention is vital. To summarize, any savoring attempt has three components: A target that spurs positive emotion, the positive emotion itself, and our attention to the positive emotion.

    Target  Positive Emotions Attention

    Savoring is like warming up by a bonfire—a metaphor you can use with clients. The wood fueling the fire is the savoring target. The fire and its heat are positive emotions. Intentionally approaching the fire, reaching out your palms, and feeling the warmth make up the act of savoring. We need all three parts—wood, fire, and will—to savor. Client work with savoring involves identifying and creating targets (fuel), as well as training skills for drawing attention to positive emotions (warming). We do so in ways that notice, intensify, and prolong the good feelings. We’ll get to concrete ways to do that in part 2 of this primer.

    First though, it's worth noting that targets have traditionally been sorted into three types (Bryant, 2003). Their distinctions are based on the target’s timeframe—past, present, or future. Reminiscing is when remembering a moment from the past generates positive emotion, which we can then savor. Vividly recalling last year’s vacation to Japan is a reminiscing target. Savoring the moment is when we savor positive emotions from the here-and-now. Enjoying the simmering sensations of a winter hot tub fits this kind of target. Anticipation is when a thought about something we expect to happen in the future gives us positive emotion (like excitement or hope). Looking forward to a weekend party is an anticipation target. You can use any of these as material for client savoring practices—memories, current experiences, or rosy expectations. Yet note that the actual savoring is always occurring in the present moment. We savor positive emotions that are here with us, now. For this reason, it’s often present-moment techniques that make for the most productive practice. You may want to prioritize ‘present’ exercises in training, both in and out of session. Note that the attention and awareness elements of classic mindfulness practices can strongly support this work. This is especially true if the client needs to first build basic attentional skills (e.g., focusing on breath, body scans, monitoring emotion, etc.). Yet even if the current moment is key, thoughts about the past or future can certainly generate positive emotions, which we then enjoy in the present.

    What Savoring Is Not

    For clients to truly grasp the meaning of savoring, it’s helpful to discuss what savoring is not. Misconceptions about savoring can interfere with clients’ adherence and success, especially if they create an unwarranted skepticism (doubts which, unfortunately, often go unspoken). By explicitly discussing common false beliefs in our psychoeducation, we can “head off” misunderstandings. First, we should acknowledge that savoring is not intended to be a cure for everything. It has important and beneficial uses, but it’s not meant to solve every ill or gather every gain. Savoring is one tool in our toolbox—a complement to the many others we have at our disposal. Oftentimes clients have misguided views that anything “positive” is juvenile, unrealistic, fraudulent, or otherwise “mockable” in some way. To present savoring as a panacea only further provokes this cynicism. Make its value clear, but be careful not to oversell it. Second, savoring is not “positive thinking”—it’s not “finding the silver lining,” nor keeping our thoughts “on the sunny side.” This is partly because savoring isn’t even about thinking—at least not primarily. Savoring is about feeling and experiencing our good feelings. Thoughts can be a target that bring up these feelings, but savoring itself is experiential. We’re not challenging negative beliefs with positive evidence here. We’re simply engaging with positive emotions. Moreover, positive thinking may invalidate or overlook the very real negative elements of client’s lives.

    Which brings me to my third point: Savoring is not suppressing pain or dismissing problems. Just as we acknowledge and validate joy in our savoring, good treatment should also acknowledge and validate client’s trials and troubles. We are savoring in addition to managing negative thoughts, emotions, and situations—not “instead of.” We don’t use savoring in the service of pushing down pain or avoiding our struggles. Savoring runs to wellbeing, not away from pain. Acceptance practices are a good complement to this work (Chin et al., 2019). Acceptance can help clients drop their wrestling match with negative emotions, freeing them up to enjoy more fully. As for savoring, it’s a means to engage with the joys that life does present to us, even amidst our challenges. Sure, there are times when we have to make life’s lemons into lemonade. But when life gives you oranges, you can just eat them raw—sweet and succulent just as they are! Savoring is juicing all the goodness life gives us, in whatever form or measure it may come.

    Continued in Part 2: Core Procedures and Exercises

    We’re far from done! To continue on and learn specific procedures and exercises for training savoring, follow this link to Part 2: A Primer for Training Savoring Skills in Psychotherapy (Part 2): Core Procedures and Exercises.

    Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., & Bohlmeijer, E. (2013). Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health, 13(1), 1-20.

    Bryant, F. B. (2003). Savoring beliefs inventory (SBI): A scale for measuring beliefs about savoring. Journal of Mental Health, 12(2), 175-196.

    Catalino, L. I., Algoe, S. B., & Fredrickson, B. L. (2014). Prioritizing positivity: An effective approach to pursuing happiness? Emotion, 14(6), 1155-1161.

    Chin, B., Lindsay, E. K., Greco, C. M., Brown, K. W., Smyth, J. M., Wright, A. G. C., & Creswell, J. D. (2019). Psychological mechanisms driving stress resilience in mindfulness training: A randomized controlled trial. Health Psychology, 38(8), 759–768.

    Corman, M., Aubret, D., Ghazal, J., Berthon, M., Chausse, P., Lohou, C., & Dambrun, M. (2020). Attentional bias modification with a new paradigm: The effect of the Detection Engagement and Savoring Positivity (DESP) task on eye-tracking of attention. Journal of Behavior Therapy and Experimental Psychiatry, 68, 1-8.

    Craske, M. G., Meuret, A. E., Ritz, T., Treanor, M., Dour, H., & Rosenfield, D. (2019). Positive affect treatment for depression and anxiety: A randomized clinical trial for a core feature of anhedonia. Journal of Consulting and Clinical Psychology, 87(5), 457-471.

    Doorley, J. D., & Kashdan, T. B. (2021). Positive and negative emotion regulation in college athletes: A preliminary exploration of daily savoring, acceptance, and cognitive reappraisal. Cognitive Therapy and Research,45(5), 598-613.

    Fredrickson, B. L., Mancuso, R. A., Branigan, C., & Tugade, M. M. (2000). The undoing effect of positive emotions. Motivation and Emotion, 24(4), 237-258.

    Garland, E. L., Fredrickson, B., Kring, A. M., Johnson, D. P., Meyer, P. S., & Penn, D. L. (2010). Upward spirals of positive emotions counter downward spirals of negativity. Clinical Psychology Review,30(7), 849-864.

    Gloria, C. T., & Steinhardt, M. A. (2016). Relationships among positive emotions, coping, resilience and mental health. Stress & Health, 32(2), 145-156.

    Jose, P. E., Lim, B. T., & Bryant, F. B. (2012). Does savoring increase happiness? A daily diary study. The Journal of Positive Psychology, 7(3), 176-187.

    Kiken, L. G., Lundberg, K. B., & Fredrickson, B. L. (2017). Being present and enjoying it: Dispositional mindfulness and savoring the moment are distinct, interactive predictors of positive emotions and psychological health. Mindfulness (N Y), 8(5), 1280-1290.

    LaFreniere, L. S., & Newman, M. G. (2023a). Reducing contrast avoidance in GAD by savoring positive emotions: Outcome and mediation in a randomized controlled trial. Journal of Anxiety Disorders, 93, 102659.

    LaFreniere, L. S., & Newman, M. G. (2023b). Upregulating positive emotion in generalized anxiety disorder: A randomized controlled trial of the SkillJoy ecological momentary intervention. Journal of Consulting and Clinical Psychology, 91(6), 381-387.

    Quoidbach, J., Berry, E. V., Hansenne, M., & Mikolajczak, M. (2010). Positive emotion regulation and well-being: Comparing the impact of eight savoring and dampening strategies. Personality and Individual Differences, 49, 368-373.

    Rosen, F. N., & LaFreniere, L. S. (2023). Savoring, worry, and positive emotion duration in generalized anxiety disorder: Assessment and interventional experiment. Journal of Anxiety Disorders, 97, 102724.

    Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology: In Session, 65(5), 467-487.

    Smith, J. L., & Bryant, F. B. (2017). Savoring and well-being: Mapping the cognitive-emotional terrain of the happy mind. In M. D. Robinson & M. Eid (Eds.), The happy mind: Cognitive contributions to well-being (pp. 139-156). Springer.

    Smith, N. K., Larsen, J. T., Chartrand, T. L., Cacioppo, J. T., Katafiasz, H. A., & Moran, K. E. (2006). Being bad isn't always good: Affective context moderates the attention bias toward negative information. Journal of Personality and Social Psychology, 90(2), 210-220.

    Wilson, K. A., & MacNamara, A. (2021). Savor the moment: Willful increase in positive emotion and the persistence of this effect across time. Psychophysiology, 58(3), e13754.

    Published August 25, 2023

  • 08/31/2022 9:14 AM | Anonymous

    Brian Pilecki, PhD - Oregon Health and Science University & Portland Psychotherapy

    Over the last decade there has been a significant increase in research on the potential of psychedelic-assisted therapy (PAT) to treat various mental health conditions. PAT was originally developed in the 1960’s and used to address such disorders as alcohol abuse and schizophrenia. Research into this novel form of treatment stopped in the early 1970’s when LSD and other psychedelics became scheduled substances that were deemed to have no medical value. Due to various factors such as loosening restrictions, the need for improvements in mental health treatment, and the persistence of advocates of psychedelics, there has been a surge of clinical research that has reconsidered PAT as a tool for addressing mental health problems. Early-stage trials indicate that psilocybin, the psychoactive component in “magic mushrooms,” may be effective in treating end-of-life anxiety, treatment-resistant depression, major depressive disorder, and substance use disorders (Agin-Liebes et al., 2020; Bogenschutz et al., 2015; Carhart-Harris et al., 2021; Davis et al., 2021; Garcia-Romeu et al., 2019; Griffiths et al., 2016; Luoma, Chwyl, Bathje, Davis, & Lancelotta, 2020; Swift et al., 2017). MDMA, a drug more commonly known as “molly” or “ecstasy,” has also been tested in the treatment of post-traumatic stress disorder (PTSD) and  shown to result in large effect size differences compared to placebo controls in Phase II and Phase 3 trials (Mitchell et al., 2019; Mithoefer et al., 2019). The FDA granted breakthrough therapy status to both MDMA-assisted therapy for PTSD (Feduccia, 2019) and psilocybin-assisted therapy for treatment-resistant depression (Lowe et al., 2021). It estimated that each will become approved and available treatments sometime over the next several years.

    PAT is a unique combination of both psychotherapy and a drug-induced altered state of consciousness. While PAT differs based upon the particular psychedelic that is used, there is a basic model emerging from the clinical trials that involves three components (Schenberg, 2018). First, in preparation sessions, participants are provided with basic information about the drug that they will be taking, what to expect on the day of ingestion, and how this treatment relates to their mental health problems. A safe, supportive environment is created with typically two therapists present throughout all the sessions. Second, the dosing session involves taking the drug and can last anywhere from 3-8 hours depending on the length of effects. With the aid of eyeshades and music, participants are mostly encouraged to focus on their inner experience while therapists employ a non-directive, open, and supportive approach. Finally, integration sessions involve processing the experience with a focus on how new thoughts, feelings, or memories may relate to the participant’s treatment goals. Because psychedelic experiences do not automatically translate to behavior change, integration sessions are important in helping enhance therapeutic benefits associated with psychedelics.

    The legal status of psychedelics can be confusing. Many clients encounter news about PAT or decriminalization of psychedelics, but often do not realize that psychedelics remain largely illegal. Some clients are looking to use psychedelics now and are bringing this interest up for discussion with their current therapist. Therefore, it is helpful for therapists to have some basic knowledge of psychedelics and how they might be relevant for certain conditions. Some therapists with a specialty in this area offer harm reduction and integration therapy for clients who are using psychedelics on their own (Gorman, Nielson, Molinar, Cassidy, & Sabbagh 2021). While incorporating clients’ use of illegal drugs may sound risky to professionals, there are several guidelines that can help providers understand the associated risks and ways to mitigate them (Pilecki, Luoma, Bathje, Rhea, & Narloch, 2021). For example, make it clear on your website that you don’t provide illegal drugs and obtain CE’s related to psychedelic integration to demonstrate competence in this burgeoning clinical area.

    While most early research on PAT has focused on outcomes using symptom severity measures, there has been less focus on underlying processes of change relevant to PAT. Understanding why psychedelic experiences produce therapeutic change is important in informing the psychotherapy components (e.g. preparation, integration) of PAT. For example, some evidence suggests that the degree to which a participant has a mystical experience predicts outcomes related to reductions in anxiety and depression in a trial of psilocybin-assisted therapy for end-of-life distress (Griffiths et al., 2016). Investigation into what therapy models are the best fit for PAT is still in its infancy, as there are not yet any trials comparing different psychotherapy interventions for psilocybin or MDMA. CBT (Yaden et al., 2022) and ACT (Luoma, Sabucedo, Eriksson, Gates, & Pilecki, 2019) have been identified as good candidates for informing PAT, and many of the recent psilocybin trials have already used ACT as a foundation for their therapeutic models. I am one of the study therapists on a clinical trial of MDMA-assisted therapy for social anxiety disorder that is taking place at Portland Psychotherapy (Lear, Smith, Pilecki, Stauffer, & Luoma, under review). One of our aims is to better understand how MDMA might enhance underlying processes of psychological flexibility that lead to therapeutic growth in individuals with social anxiety.

    While recent research has demonstrated that both psilocybin and MDMA can be administered safely in the context of psychedelic-assisted therapy, using psychedelics is not without risk. In uncontrolled environments, such as taking psychedelics in a public setting (e.g. club, music festival), there is greater potential for psychological difficulties to occur, such as paranoia and fear. Taking a psychedelic, especially at substantive doses such as those used in the trials, is often an ordeal and should be approached with thoughtfulness and preparation. When in the safe container of a therapeutic environment, challenging experiences with psychedelics can be navigated well and often result in therapeutic growth. In many ways, this is no different that standard therapy that often involves confronting painful emotions or memories. Another risk of taking psychedelics in any context is that one is place into a vulnerable state in which even physical mobility may be dependent on others. As a result, the potential for abuse and boundary violations may be greater than in traditional psychotherapy. Finally, PAT will likely be initially expensive and may not be covered by insurance. This creates problems such as lack of access for marginalized populations.

    In summary, we are just beginning to scratch the surface of understanding about under what conditions and for whom  PAT may be helpful or not and , how to best use psychotherapy to support growth from psychedelic experiences, and how this new treatment works. However, initial data from rigorous placebo-controlled randomized trials suggests that PAT may be another tool that we can use, especially in cases where clients have not responded to existing treatment options.

    Agin-Liebes, G. I., Malone, T., Yalch, M. M., Mennenga, S. E., Ponté, K. L., Guss, J., Bossis, A. P., Grigsby, J., Fischer, S., & Ross, S. (2020). Long-term follow-up of psilocybin-assisted psychotherapy for psychiatric and existential distress in patients with life-threatening cancer. Journal of Psychopharmacology, 34, 155-166.

    Bogenschutz, M. P., Forcehimes, A. A., Pommy, J. A., Wilcox, C. E., Barbosa, P. C. R., & Strassman, R. J. (2015). Psilocybin-assisted treatment for alcohol dependence: A proof-of-concept study. Journal of Psychopharmacology, 29, 289–299.

    Carhart-Harris, R., Giribaldi, B., Watts, R., Baker-Jones, M., Murphy-Beiner, A., Murphy, R., Martell, J., Blemings, A., Erritzoe, D., & Nutt, D. J. (2021). Trial of psilocybin versus escitalopram for depression. New England Journal of Medicine384(15), 1402-1411.

    Davis, A. K., Barrett, F. S., May, D. G., Cosimano, M. P., Sepeda, N. D., Johnson, M. W., Finan, P. H., & Griffiths, R. R. (2021). Effects of psilocybin-assisted therapy on major depressive disorder: a randomized clinical trial. JAMA Psychiatry78, 481-489.

    Feduccia, A. A., Jerome, L., Yazar-Klosinski, B., Emerson, A., Mithoefer, M. C., & Doblin, R. (2019). Breakthrough for Trauma Treatment: Safety and Efficacy of MDMA-Assisted Psychotherapy Compared to Paroxetine and Sertraline. Frontiers in psychiatry10, 650.

    Garcia-Romeu, A., Davis, A. K., Erowid, F., Erowid, E., Griffiths, R. R., & Johnson, M. W. (2019). Cessation and reduction in alcohol consumption and misuse after psychedelic use. Journal of psychopharmacology (Oxford, England)33, 1088–1101.

    Gorman, I., Nielson, E.M., Molinar, A., Cassidy, K., & Sabbagh, J. (2021). Psychedelic harm reduction and integration: A transtheoretical model for clinical practice. Frontiers in Psychology, 12:645246.

    Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D.Cosimano, M. P., & Klinedust, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of Psychopharmacology, 30,1181–1197.

    Lear, K.M., Smith, S.M., Pilecki, B., Stauffer, C., & Luoma, J. (under review). Social anxiety and MDMA-assisted therapy investigation (SAMATI): A novel clinical trial protocol.

    Lowe, H., Toyang, N., Steele, B., Valentine, H., Grant, J., Ali, A., Ngwa, W., & Gordon, L. (2021). The Therapeutic Potential of Psilocybin. Molecules26, 2948.

    Luoma, J.B., Sabucedo, P., Eriksson, J., Gates, N.A., & Pilecki, B. (2019). Toward a contextual psychedelic-assisted therapy: Perspectives from Acceptance and Commitment Therapy and contextual behavioral science. Journal of Contextual Behavioral Science, 14, 136-145.

    Luoma, J. B., Chwyl, C., Bathje, G. J., Davis, A. K., & Lancelotta, R. (2020). A meta-analysis of placebo-controlled trials of psychedelic-assisted therapy. Journal of Psychoactive Drugs, 52, 288-299.

    Mitchell, J. M., Bogenschutz, M., Lilienstein, A., Harrison, C., Kleiman, S., Parker-Guilbert, K., Ot'alora G, M., Garas, W., Paleos, C., Gorman, I., Nicholas, C., Mithoefer, M., Carlin, S., Poulter, B., Mithoefer, A., Quevedo, S., Wells, G., Klaire, S. S., van der Kolk, B., Tzarfaty, K., … Doblin, R. (2021). MDMA-assisted therapy for severe PTSD: a randomized, double-blind, placebo-controlled phase 3 study. Nature medicine27, 1025–1033.

    Mithoefer, M. C., Feduccia, A. A., Jerome, L., Mithoefer, A., Wagner, M., Walsh, Z., Hamilton, S., Yazar-Klosinski, B., Emerson, A., & Doblin, R. (2019). MDMA-assisted psychotherapy for treatment of PTSD: study design and rationale for phase 3 trials based on pooled analysis of six phase 2 randomized controlled trials. Psychopharmacology236, 2735–2745.

    Pilecki, B., Luoma, J., Bathje, G.J., Rhea, J., & Narloch, V.F. (2021). Ethical and legal issues in psychedelic harm reduction and integration therapy. Harm Reduction Journal, 18, 40.

    Schenberg E. E. (2018). Psychedelic-Assisted Psychotherapy: A Paradigm Shift in Psychiatric Research and Development. Frontiers in pharmacology9, 733.

    Swift, T. C., Belser, A. B., Agin-Liebes, G., Devenot, N., Terrana,S., Friedman, H. L., Guss, J., Bossis, A. P., & Ross, S. (2017). Cancer at the dinner table: Experiences of psilocybin-assisted psychotherapy for the treatment of cancer-related distress. Journal of Humanistic Psychology, 57, 488–519.

    Yaden, D. B., Earp, D., Graziosi, M., Friedman-Wheeler, D., Luoma, J. B., & Johnson, M. W. (2022). Psychedelics and Psychotherapy: Cognitive-Behavioral Approaches as Default. Frontiers in Psychology13, 873279.

    Published August 31, 2022

  • 03/23/2022 9:20 AM | Anonymous

    Lizabeth Roemer, PhD - University of Massachusetts Boston

    Sue Orsillo and I recently (well, recently by pandemic times in which time has no meaning) published a therapist-focused book, Acceptance-based behavioral therapy: Treating anxiety and related challenges (2020, Guilford Press). This clinical guide is grounded in our two decades of collaborative work that began with developing an acceptance-based behavioral therapy for clients with a principal diagnosis of generalized anxiety disorder (GAD; along with a range of comorbid disorders; Roemer & Orsillo, 2002; Roemer, Eustis, & Orsillo, 2021) and evolved into a flexible, conceptualization-driven acceptance-based behavioral approach to a range of clinical presentations and health promotion efforts. Our initial manualized treatment drew from several evidence-based interventions that emphasize acceptance and mindfulness (e.g., acceptance and commitment therapy [ACT]: Hayes, Strosahl, & Wilson, 1999; dialectical behavior therapy [DBT]: Linehan, 1993; mindfulness-based cognitive therapy [MBCT]: Segal, Williams, & Teasdale, 2002), as well as other behavioral and cognitive interventions with extensive empirical support (e.g., Barlow, 2014; Borkovec & Sharpless, 2004).

    In our work, we use the term acceptance-based behavioral therapies (ABBTs; or sometimes mindfulness- and acceptance-based behavioral therapies) to define an overarching approach that explicitly emphasizes altering the way clients relate to their internal experiences (reducing reactivity and avoidance, while promoting decentering and acceptance) as a central mechanism of therapeutic change, coupled with an emphasis on helping clients to identify what matters to them and make intentional choices consistent with those values. While we draw from ACT, DBT, and MBCT strategies in our work, we also draw from more “traditional” CBT strategies such as self-monitoring, psychoeducation, adapted relaxation practices, and behavioral activation. We focus particularly on the function of interventions (i.e., helping clients change their relationships with internal experiences, increasing clients’ willingness to experience distress, helping clients to connect to what matters to them, helping clients to choose their actions intentionally), rather than adhering to strict prescriptions of the form of interventions.

    Our collaborative research with colleagues and doctoral students focused first on developing an ABBT protocol for treating clients with GAD and comorbid presenting problems. This treatment leads to significant reductions in symptoms of anxiety and depression, improvements in quality of life that is comparable to that found with applied relaxation (e.g., Roemer, Orsillo, & Salters-Pedneault, 2008; Hayes-Skelton, Roemer, & Orsillo, 2013), as well as improvements in interpersonal functioning (Millstein, Orsillo, Hayes-Skelton, & Roemer, 2015) and clinically significant increases in self-reported engagement in values-based action (Michelson, Lee, Orsillo, & Roemer, 2011). Both ABBT and applied relaxation targeted experiential avoidance and decentering and these changes predicted clinical outcomes (Eustis, Hayes-Skelton, Roemer, & Orsillo, 2016; Hayes-Skelton, Calloway, Roemer, & Orsillo, 2015), with decentering changing prior to anxiety symptoms. Clients from marginalized backgrounds reported that values clarification/action and flexibility helped with the cultural responsiveness of the therapy (Fuchs et al., 2016).  Abbreviated health promotion programs developed based on these principles also significantly reduced anxiety and depressive symptoms through programs delivered in person (Danitz & Orsillo, 2014; Danitz, Suvak, & Orsillo, 2016; Eustis, Krill Williston, Morgan, Graham, Hayes-Skelton, & Roemer, 2017) and on-line (Eustis, Hayes-Skelton, Orsillo, & Roemer, 2018; Sagon, Danitz, Suvak, & Orsillo, 2018). We also have preliminary data suggesting that individuals in the community with generalized anxiety who used our self-help workbook, Worry less, live more: The mindful way through anxiety workbook experienced significant decreases in worry, anxiety, depression and functional impairment and increases in acceptance (Serowik, Roemer, Suvak, Liverant, & Orsillo, 2019).  Correlational and experimental pilot studies have also illustrated the ways that mindfulness and values-based action may be beneficial in response to racist experiences (Graham, West, & Roemer, 2013; Graham, West, & Roemer, 2015; Miller & Orsillo, 2020; West, Graham, & Roemer, 2013). Most recently, several colleagues and I published clinical guidance for applying both mindfulness and valued living interventions to racism-related stress (Martinez, Suyemoto, Abdullah, Burnett-Ziegler & Roemer, 2022).

    In my upcoming training for PBTA, I will be drawing from this body of research, from my experience supervising clinicians in the context of randomized controlled trials and in the context of clinical practica, and from the wisdom of experts in acceptance-based and other behavioral approaches (e.g., Harrell, 2018) to provide guidance on using both mindfulness and values-based action with clients who present with a range of anxiety experiences, including those experiencing racism- and other kinds of discrimination-related stress. I will focus particularly on how to clarify values with clients and develop meaningful values-based actions, taking into account systemic factors and other complexities. I look forward to seeing many of you there!

    Barlow, D. H. (Ed). (2014). Clinical handbook of psychological disorders: A step by-step treatment manual (5th ed.). New York, NY: Guilford Press.

    Borkovec, T. D., & Sharpless, B. (2004). Generalized anxiety disorder: Bringing cognitive-behavioral therapy into the valued present. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 209-242). New York. NY: Guilford Press.

    Danitz, S. B., & Orsillo, S. M. (2014). The mindful way through the semester: An investigation of the effectiveness of an acceptance-based behavioral therapy program on psychological wellness in first-year students. Behavior Modification, 38, 549-566

    Danitz, S. B., Suvak, M., Orsillo, S. M. (2016). The Mindful Way Through the Semester: Evaluating the impact of integrating an acceptance-based behavioral program into a first-fear experience course for undergraduates. Behavior Therapy, 47, 487-499.

    Eustis, E.H., Hayes-Skelton, S. A., Orsillo, S. M., & Roemer, L. (2018). Surviving and thriving during stress: A randomized clinical trial comparing a brief web-based therapist assisted acceptance-based behavioral intervention versus waitlist control for college students. Behavior Therapy, 49, 889-903

    Eustis, E.H., Hayes-Skelton, S. A., Roemer, L.,&Orsillo, S.M. (2016). Reductions in experiential avoidance as a mediator of change in symptom outcome and quality of life in acceptance-based behavior therapy and applied relaxation for generalized anxiety disorder. Behaviour Research and Therapy, 87, 188-195.

    Eustis, E. H., Williston, S. K., Morgan, L. P., Graham, J. R., Hayes-Skelton, S. A., & Roemer, L. (2017). Development, acceptability, and effectiveness of an acceptance-based behavioral stress/anxiety management workshop for university students. Cognitive and Behavioral Practice, 24, 174-186.

    Fuchs, C. H., West, L. M., Graham, J. R., Kalill, K. S., Morgan, L. P., Hayes-Skelton, S. A., ... & Roemer, L. (2016). Reactions to an acceptance-based behavior therapy for GAD: Giving voice to the experiences of clients from marginalized backgrounds. Cognitive and Behavioral Practice23(4), 473-484.

    Graham, J. R., West, L., & Roemer, L. (2013). The experience of racism and anxiety symptoms in an African American Sample: Moderating effects of trait mindfulness. Mindfulness, 4, 332-341.

    Graham, J. R., West, L. M., & Roemer, L. (2015). A preliminary exploration of the moderating role of valued living in the relationships between racist experiences and anxious and depressive symptoms. Journal of Contextual Behavioral Science, 4, 48-55.

    Harrell, S. P. (2018). Soulfulness as an orientation to contemplative practice: Culture, liberation, and mindful awareness. The Journal of Contemplative Inquiry, 5(1), 9-40.

    Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). New York, NY: Guilford Press.

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    Published March 23, 2022

  • 02/26/2022 9:26 AM | Anonymous

    Denise M Sloan, PhD - National Center for PTSD at VA Boston Healthcare System & Boston University School of Medicine

    Nearly 20 years ago, Dr. Brian Marx and I conducted our first study of expressive writing (Sloan & Marx, 2004). We were intrigued by the results from a systematic line of research by James Pennebaker and colleagues (e.g., Pennebaker and Beall, 1986) in which they had participants write about their most traumatic or stressful life event on three consecutive days for 20 minutes each time sessions. We were quite surprised, and skeptical to be honest, with the consistent, significant symptom improvements observed across Pennebaker and colleagues’ studies as well as the hundreds of expressive writing studies that followed in their wake (for a review see, Frattaroli, 2006).  As we read the details of these studies, we were struck by the similarity of the expressive writing protocol to exposure-based treatments for posttraumatic stress disorder (PTSD), such as Prolonged Exposure (PE; Foa et al., 2019). Yet, despite the procedural similarity of asking individuals to recount the details of traumatic experiences, we were not convinced that writing about one’s trauma for only 20 minutes during three consecutive sessions would be enough of a therapeutic dose to result in significant decreases in PTSD symptoms among individuals who had experienced a bona fide traumatic stressor and had at least moderately severe PTSD symptoms. However, this was exactly what we found (Sloan & Marx, 2004).

    These initial findings made us question what was known about how to best treat PTSD and, more specifically, how many therapy sessions might be necessary for good clinical outcomes. Following our initial study, other researchers have demonstrated that PTSD can be successfully treated with fewer therapy sessions than was previously thought necessary (Galovski et al., 2012; Natsh et al., 2015; van Minnen & Foa, 2006). The results of our first study were so intriguing to us that we wanted to follow it up with a second study. The findings of that second study resulted in a series of studies examining the use of expressive writing to treat PTSD and comorbid disorders experienced by trauma survivors (see, Sloan & Marx for a summary, 2017). This work ultimately led to the development of the written exposure therapy (WET) protocol (Sloan & Marx, 2019), a five-session treatment for PTSD, with no between-session homework assignments.  

    We have conducted several randomized clinical studies examining the efficacy and effectiveness of the WET protocol. The first study found WET to be efficacious in treating PTSD among individuals who had PTSD resulting from a motor vehicle accident (Sloan et al., 2012). Not only did we observe a large difference in PTSD symptoms at follow-up between individuals assigned to WET and those randomized to a wait-list condition, but we also found that, whereas 88% of individuals randomized to the wait-list condition continued to have PTSD at follow-up, only 9% of individuals randomized to WET still met criteria for PTSD at post-treatment assessment. We also found that only 8% of the participants assigned to WET prematurely dropped out of treatment. This dropout rate is much lower than to the usual dropout rate of approximately 36% for trauma-focused treatments (Imel et al., 2013).

    The next study directly compared WET with a more time intensive (12 treatment sessions) evidence-based PTSD treatment, Cognitive Processing Therapy (CPT; Resick et al., 2017). Findings indicated that 126 adults randomized to both treatment conditions had a significant reduction in PTSD symptoms (Sloan et al., 2018). Notably, despite the shorter treatment, WET was found to be non-inferior to CPT in terms of PTSD treatment outcome. Again, the number of individuals dropping out of WET was very low compared to the number of those dropping out of CPT (6% vs. 39%).  We found no differences between the two treatments in terms of treatment expectancy ratings at the beginning of treatment, treatment satisfaction ratings at the end of treatment, or client and therapist ratings of therapeutic alliance at the end of treatment (Sloan et al., 2018). Moreover, treatment gains for both WET and CPT were maintained for a year (Thompson-Hollands et al., 2018).

    These findings were replicated in a recently completed study that compared WET with the cognition only version of the CPT protocol, which does not include the written account component of the protocol (Resick et al., 2017), with 169 active duty service members with PTSD (Sloan et al., 2022). Service members randomized to both treatments displayed significant reductions in PTSD symptoms. Once again, treatment outcome for WET was non-inferior to CPT. Although the number of treatment dropouts for WET was notably higher than what we had seen previously (24%), the rate of dropout for CPT was significantly greater (45%).

    We also have findings of WET delivered in routine care settings. The United States Veterans Health Administration (VHA) has been training mental health providers in the delivery of WET for the past several years. Patient outcome data from WET being used in routine clinical practice have been collected as part of this training initiative and these findings have been recently reported (LoSavio et al., in press).  Results of this WET implementation project show significant, large reductions in PTSD symptoms. Notably, these outcomes are similar to those observed from implementation efforts within VA for both PE and CPT (Eftekhari et al., 2013). These findings further demonstrate that WET produces treatment outcomes similar to more time intensive trauma-focused treatments, even in routine care settings. In addition, WET delivered by mental health providers working in a college counseling center has also been shown to be effective in treating PTSD symptoms (Morissette et al., in press).

    Over the course of our work on WET, we have examined whether WET works better for some patients than others. Notably, we have not found any patient characteristics that impact WET treatment outcomes. More specifically, baseline PTSD symptom severity, presence of comorbid depression, substance use or other mental disorders, time since trauma exposure, number of traumas, trauma type, patient gender, age, ethnicity, race, estimated intelligence, and educational level (e.g., Marx, Thompson-Hollands, et al., 2021; LoSavio et al., in press) do not affect client outcomes for WET.  In addition, there is no treatment outcome differences found when WET is delivered in person versus remotely (LoSavio et al., in press).

    There are a number of studies in progress that are examining the utility of WET in various settings such as primary care, residential substance use programs, and inpatient psychiatry (Marx, et al., 2021). Some of these studies are also examining the spacing of treatment sessions (e.g., sessions delivered on consecutive days, multiple sessions in a day). There is a continuing effort to better understand the most efficient and effective methods to disseminate the treatment so that a greater number of providers can deliver WET (e.g., Worley et al., 2020). Lastly, the WET treatment protocol has been translated into Spanish and early results of this version of the protocol are promising (Andrews et al., in press). One area that needs greater attention is the application of WET with children and adolescents with PTSD. We have heard anecdotal reports from providers that WET can yield good outcomes with adolescents but there has yet to be an empirical study in this area.

    We have come a long way in the past 20 years in terms of both developing a more efficient treatment for PTSD and establishing that WET is an effective treatment for a variety of individuals and can be used in a variety of settings. We are pleased to hear from providers that they appreciate having another treatment approach to offer their clients.  We are excited by the number of investigators who are conducting treatment studies with WET, and we look forward to findings that will be produced by these studies.

    Andrews, A.R., Acosta, L., Acosta Canchila, M.N., Haws, J.K., Holt, N.R., Holland, K.J., & Ralston, A.L. (in press). Perceived barriers and preliminary PTSD outcomes in an open pilot trial of Written Exposure Therapy with Latinx immigrants. Cognitive and Behavioral Practice.

    Eftekhari, A., Ruzek, J. I., Crowley, J. J., Rosen, C. S., Greenbaum, M. A., & Karlin, B. E. (2013). Effectiveness of national implementation of prolonged exposure therapy in Veterans Affairs care. JAMA Psychiatry, 70(9), 949–955.

    Foa, E. B., Hembree, E. A., Rothbaum, B. O., & Rauch, S. A. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences (2nd ed.). Oxford University Press.

    Frattaroli, J. (2006). Experimental disclosure and its moderators: a meta-analysis. Psychological Bulletin, 132, 823-865.

    Galovski, T. E., Blain, L. M., Mott, J. M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80(6), 968–981.

    Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81(3), 394-404.

    LoSavio, S. T., Worley, C. B., Aajmain, S., Rosen, C., Stirman, S. W., & Sloan, D. M. (in press). Effectiveness of Written Exposure Therapy for posttraumatic stress disorder in the Department of Veterans Affairs Healthcare System. _Psychological Trauma: Theory, Research, Practice, and Policy. _

    Marx, B. P., Fina, B. A., Sloan, D. M., Young-McCaughan, S., Dondanville, K. A., Tyler, H. C., Blankenship, A. E., Schrader, C. C., Kaplan, A. M., Greene, V. R., Bryan, C. J., Hale, W. J., Mintz, J., & Peterson, A. L., for the STRONG STAR Consortium. (2021). Written exposure therapy for posttraumatic stress symptoms and suicide risk: Design and methodology of a randomized controlled trial with patients on a military psychiatric inpatient unit. Contemporary Clinical Trials, _110,_106564.

    Marx, B. P., Thompson-Hollands, J., Lee., D. J., Resick, P. A., & Sloan, D. M. (2021). Estimated intelligence moderates Cognitive Processing Therapy outcome for posttraumatic stress symptoms. Behavior Therapy, 52(1), 162-169.

    Morissette, S. B., Ryan-Gonzalez, C., Blessing, A., Judkins, J., Crabtree, M., Hernandez, M., Wiltsey-Stirman, S., & Sloan, D. M. (in press). Delivery of Written Exposure Therapy for PTSD in a university counseling center. Psychological Services.

    Nacasch, N., Huppert, J. D., Yi-Jen, S., Kivity, Y., Dinshtein, Y., Yeh, R., & Foa, E. B. (2015). Are 60-minute prolonged exposure sessions with 20-minute imaginal exposure to traumatic memories sufficient to successfully treat PTSD? A randomized noninferiority clinical trial. Behavior Therapy, 46, 328-341.

    Pennebaker, J. W., & Beall, S. K. (1986). Confronting a traumatic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281.

    Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive processing therapy for PTSD: A comprehensive manual. Guilford Press.

    Sloan, D. M., & Marx, B. P. (2004).  A closer examination of the structured written disclosure procedure.  Journal of Consulting and Clinical Psychology, 72, 165-175.

    Sloan, D. M. & Marx, B. P. (2017). Commentary on the implementation of Written Exposure Therapy WET) for veterans diagnosed with PTSD. Pragmatic Case Studies in Psychotherapy, 13, 154-164.

    Sloan, D. M. & Marx, B. P. (2019). Written Exposure Therapy for PTSD: A Brief Treatment Approach for Mental Health Professionals. American Psychological Press.

    Sloan, D. M., Marx, B. P., Bovin, M. J., Feinstein, B. A., & Gallagher, M. W. (2012).  Written exposure as an intervention for PTSD: A randomized controlled trial with motor vehicle accident survivors.  Behaviour Research and Therapy, 50, 627-635.

    Sloan, D. M., Marx, B. P., Lee, D. J., & Resick, P. A. (2018). A brief exposure-based treatment for PTSD versus Cognitive Processing Therapy: A randomized non-inferiority clinical trial. JAMA Psychiatry, 75, _233-239.

    Sloan, D. M., Marx, B. P., Resick, P. A., Young-McCaughan, S., Dondaville, K. A., Straud, C. L., Mintz, J., Litz, B., Peterson, A. L., and for the STRONG STAR Consortium (2022). Effect of Written Exposure Therapy versus Cognitive Processing Therapy on Increasing Treatment Efficiency Among Military Service Members: A Randomized Noninferiority Trial. JAMA Network Open, 5(1), e2140911.

    Thompson-Hollands, J., Marx, B. P., Lee, D. J., Resick, P. A., & Sloan, D. M. (2018). Long-term treatment gains of a brief exposure-based treatment for PTSD. Depression and Anxiety, 35- 985-991.  

    van Minnen, A., & Foa, E. B. (2006). The effect of imaginal exposure length on outcome of treatment for PTSD. Journal of Traumatic Stress, 19, 427–438.

    Worley, C.B., Losavio, S.T., Aajmain, S.A., Rosen, C., Wiltsey Stirman, S., Sloan, D.M.  (2020). Training during a pandemic: Successes, Challenges, and Practical Guidance during a virtual facilitated learning collaborative for Written Exposure Therapy. Journal of Traumatic Stress, 33(5), 634-642.

    Published February 26, 2022

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