Philadelphia Behavior Therapy Association The EBP

Meta-Competencies in CBT: Being the Best “Delivery System” for Efficacious Treatment.

Mon, 25 Aug 2025 15:48:36 GMT

Our ever-growing knowledge base for psychotherapy in general and CBT (and related therapies) in particular is the result of many decades of research on principles of human functioning and change. As a field, we have tested and found support for the benefits of teaching our clients skills such as: (1) planning and enacting behavioral activities that boost their sense of accomplishment, enjoyment, and connection, (2) approaching (rather than avoiding) uncomfortable situations that can improve their sense of self-efficacy and expand their life experiences, (3) being self-aware of physiological sensations in a way that allows for a reduction in hyper-arousal, (4) being self-aware of thoughts in a way that allows for cognitive flexibility and perspective-taking, (5) enacting problem-solving to reduce impulsivity and improve one’s life situation, (6) mindfulness, self-soothing and self-compassion methods to moderate dysregulated emotions and promote positive states of mind, (7) communication and assertiveness skills to improve interpersonal relationships, and others. These are categories of interventions in CBT that have produced so many positive outcomes across a range of clinical problem areas (Hayes & Hofmann, 2018).

Therapists are trained to deliver the above (and related) interventions to their clients to meet their individual needs, and to teach their clients to self-apply psychological skills for long-term maintenance. Imparting these interventions is part of what is known as the “functional competencies” of therapists, to go along with such related competencies as possessing diagnostic and case conceptualization skills. It is also important for us to mention the “foundational competencies” of therapists that underlie the above, such as respect for the scientific method, alliance-building skills, self-assessment and self-correction, and cross-cultural humility (Iwamasa & Hays, 2019), among others (see Newman, 2010).

Now that we have briefly summarized the competencies of the CBT therapist, what do we mean by the term meta-competencies? Loosely defined, the term “meta-competencies” refers to those qualities or characteristics that therapists bring to bear on their interactions with clients that maximize the positive impact and staying power of the interventions so that clients find therapy to be memorable, inspirational, and a catalyst for further growth (Whittington & Grey, 2014).

CBT takes a psycho-educational approach to psychotherapy, therefore it is apropos to consider the notion that to some extent therapists are in fact teachers. If we think back to our school days, we recognize that many teachers more or less competently followed a similar rubric (perhaps analogous to a therapy protocol), but some teachers were more memorable and positively influential than others (hence, they possessed greater meta-competencies). What were some of the qualities that those teachers exhibited that helped us not only to learn, but to value learning, and how can we relate these qualities to the meta-competencies of conducting CBT? We may hypothesize that the educational process works best when teachers challenge their students to think for themselves, while still offering guidance if the students struggle. Such teachers may be seen as somewhat demanding, but never demeaning, and they typically demonstrate confidence in their students’ capacity to learn, trying to instill in their students greater belief in themselves. These teachers bring life to the subject material through interesting stories, creative use of language, clarity of communication, and by encouraging lively dialogue on the subject at hand. They show genuine interest in what they are teaching – shown in part by their energy, engagement, and preparedness – and try to inculcate this level of interest in their students so they will want to continue to learn long after their coursework with the particular teacher in question is complete.

We can see how the above readily relates to the tasks that comprise competency and meta-competency in CBT. We take an evidence-based set of procedures and deliver them with a keen understanding of the sensibilities and needs of the client, based in part on having done our homework about the client’s learning history, and in part by paying close attention to the client’s verbal and non-verbal reactions in session so that we are “in tune” with them. We serve as role models for thoughtfulness, composure, sincerity, self-reflection, and perseverance. We practice congruence by utilizing for ourselves the same psychological skills we endeavor to impart to our clients (Bennett-Levy et al., 2015). This not only improves our skill set through repetition, but provides us with enhanced empathy for the clients’ experiences in utilizing interventions, and boosts our hopefulness about therapeutic change because we undergo it ourselves.

The following is a non-exhaustive list of the characteristics we may call meta-competencies – qualities that are not always mentioned in CBT treatment protocols but that play significant roles nonetheless. Some of these meta-competencies have an extensive and ever-growing evidence base (e.g., repairing ruptures in the therapeutic alliance), and some have considerably less of a data base (e.g., matters of timing in delivering interventions), but let us take a glance at some of these hypothesized factors just the same:

Interweaving the therapeutic relationship with case conceptualization and interventions: The positive power of therapy is amplified when therapists can weave together their conceptual understanding of their clients’ background and current life situation into their manner of interacting with the clients in the here and now (thus being able to express accurate empathy), along with introducing and explaining interventions that fit the needs of the clients and make sense to them.
Juggling multiple lines of discussion across sessions and within sessions: For maximum breadth of coverage of relevant agenda items, therapists have to keep track of multiple topics, goals, and life circumstances of their clients. Therapists who areorganized, attentive, and adept at “connecting the dots” can address a broad range of client concerns, doing so without ever getting too far off track or losing sight of the central themes being addressed. Being prompt and thorough with clinical documentation assists this process.
Having an interdisciplinary fund of knowledge: When therapists have a range of personal interests, are well-read, are “students of life,” and learn from each of their clients, they continually improve their ability to connect with their clients by alluding to relevant subject material that clients find personally interesting and compelling (e.g., regarding current events, history, arts and literature, the substance of the client’s profession, the details of the client’s hobbies, the language and customs of the client’s culture, etc.).
Valuing self-reflection, self-correction, and personal growth: When therapists self-reflect on their work, this is considered a foundational competency in doing psychotherapy. When therapists value thoughtful self-reflection and self-correction as a way of life, it is a meta-competency that helps them develop and mature as human beings, which in turn assists them in their work (see Bennett-Levy et al., 2015).
Viewing ruptures in the therapeutic alliance as opportunities to do problem-solving. Being adept at forming and maintaining good therapeutic alliances is an important competency. Having a positive outlook about repairing alliance ruptures is a meta-competency whereby therapists model the valuable attitude, “We can work it out.” This meta-competency is related to the ability to demonstrate grace under pressure (Muran & Eubanks, 2020), as therapists may need to maintain a pleasant and hopeful demeanor even in the face of criticism and pessimism expressed by clients. Therapists who welcome the opportunities presented by doing interpersonal problem-solving will enhance both their own and their clients’ interpersonal resiliency and satisfaction.
Communicating clearly: Therapy is largely a verbal medium. Therapists express empathy, provide psycho-education, share their reflections and conceptualizations, and provide direction in how to implement a wide range of interventions. These are all important competencies in conducting therapy. What makes them meta-competencies is the therapist’s ability to be maximally comprehensible in communicating all of the above, so that clients more readily grasp and retain what the therapist is saying, without having to strain or otherwise work too hard to focus or keep track. Therapists who extensively read, write, and give academic presentations gain a lot of practice in being clear communicators.
Possessing a good sense of timing: Admittedly, this is subjective and difficult to measure. It can refer to the therapist’s cadence of verbal delivery such that what they are saying provides extra emotional emphasis (similar to the methods of skilled stand-up comedians, stage actors, and orators) or it can refer to knowing when to say something in particular, and when to wait.
Having facility in using metaphors, imagery, stories, and hypothetical questions to make the messages of therapy more vivid and compelling. Sometimes it is indeed the case that a picture (or a metaphor) is worth a thousand words (Hackmann et al., 2011; Stott et al., 2010). Similarly, a lesson of therapy embedded in an interesting vignette can make a lasting impact, Likewise, thought-provoking hypothetical questions can maximize the power of guided discovery (Newman, 2000; Waltman et al., 2021).
Knowing how and when to use the best of your personality, including humor and judicious use of self-disclosure. It is a meta-competency when therapists are adept at “using themselves,” such as by having a knack for introducing good-natured mirth and irreverent humor into a session (Linehan, 1993), and perhaps by knowing how to appropriately share one’s own feelings and experiences in the service of bonding with clients and helping them feel better understood (Farber, 2006).
Having a good memory and using it in the service of creating continuity across sessions, and inspiring clients to remember the lessons of therapy in return. For example, when therapists remember what clients said many sessions ago, they serve as role models for clients to remember what their therapists have said. To make therapy more memorable, we can use methods of “memory support” (Harvey et al., 2016) and we can demonstrate that the clients themselves are memorable.

The above-mentioned meta-competencies may be viewed as tied to the concept of “therapist effects,” referring to personal qualities and habits that make some therapists “better” than others, regardless of modality or theoretical orientation of the therapy being delivered (Castonguay & Hill, 2017). A key question is whether (and/or to what degree) these meta-competencies can be learned through formal training, and/or perhaps via personal growth endeavors (including going through therapy as clients) (see Whittington & Grey, 2014). These are intriguing questions, reminding us that maximizing the efficacy of our psychological treatments is inextricably tied to improving our capabilities as therapists in delivering these treatments.

References

Bennett-Levy, J., Thwaites, R., Haarhoff, B., & Perry, H. (2015). Experiencing CBT from the

inside out: A self-practice, self-reflection workbook for therapists. Guilford Press.

Castonguay, L. G., & Hill, C. E. (Eds.) (2017). How and why are some therapists better than

others? American Psychological Association.

Farber, B. A. (2006). Self-disclosure in psychotherapy. Guilford Press.

Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in cognitive

therapy. Oxford University Press.

Harvey, A. G., Lee, J., Smith. R. L., Gumport, N. B., Hollon, S. D., Rabe-Hesketh, S., et al.

(2016). Improving outcomes for mental disorders by enhancing memory for treatment. Behaviour Therapy and Research, 81, 35-46.

Hayes, S. C., & Hofmann, S. G. (2018) (Eds.). Process-based CBT: The science and core

clinical competencies of cognitive behavioral therapy. New Harbinger Publications.

Iwamasa, G. Y., & Hays, P. A. (Eds.) (2019). Culturally responsive cognitive behavior therapy: Practice and supervision (2nd ed.). American Psychological Association.

Linehan, M. M. (1993). Cognitive behavioral therapy of borderline personality disorder.

Guilford Press.

Muran, J. C., & Eubanks, C. E. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.

Newman, C. F. (2010). Competency in conducting cognitive-behavioral therapy: Foundational,

functional, and supervisory aspects. [For the Special Section on Psychotherapy Competencies and Supervision of Trainees]. Psychotherapy: Theory, Research, Practice, Training, 47(1), 12-19.

Newman, C. F. (2000). Hypotheticals in cognitive psychotherapy: Creative questions, novel

answers, and therapeutic change. Journal of Cognitive Psychotherapy: An

International Quarterly, 14(2), 135-147.

Stott, R., Mansell, W., Salkovskis, P., Lavender, A., & Cartwright-Hatton, S. (2010). Oxford

guide to metaphors in CBT. Oxford University Press.

Waltman, S. H., Codd, R. T. III, McFarr, L. M., & Moore, B. A. (2021). Socratic questioning

for therapists and counselors: Learn how to think and intervene like a cognitive

behavior therapist. Routledge.

Whittington, A., & Grey, N. (Eds.) (2014). How to be a more effective CBT therapist:

Mastering meta-competencies in clinical practice. Wiley Blackwell.

Fear of Cancer Recurrence (FCR) Conceptualization and Evidence-Based Treatment

Sun, 08 Jun 2025 18:15:24 GMT

Kennedy Wong, Psy.D.

Objective #1: Define Fear of Cancer Recurrence (FCR) and Its Impact on Psychological Well-Being

Fear of Cancer Recurrence (FCR) refers to the concern that cancer may return or progress (Lebel et al., 2016). It is a common worry for patients at any stage following diagnosis and can affect individuals across the cancer continuum, regardless of diagnosis or prognosis (Armes et al., 2009). In addition to FCR being a commonly reported symptom for any person affected by cancer, the prevalence is even higher among patients that are newly diagnosed, younger in age when entering survivorship, have a heightened risk perception, experienced severe treatment side effects, and have preexisting psychological conditions (Simard et al., 2013; Thewes et al., 2013). Caregivers also experience significant FCR, often with an impact similar to that of survivors (Smith et al., 2022). Addressing FCR is crucial, as reducing it can improve both psychological and functional outcomes for both patients and caregivers.

FCR can range from low, adaptive levels that motivate treatment adherence to high, clinical levels that cause significant distress and impair daily functioning (Butow et al., 2018). The Fear of Cancer Recurrence Inventory (FCRI) is one of the most frequently used, empirically validated measures to assess FCR. The short-form version of this assessment (FCRI-SF) is frequently used as a screening tool for FCR as well, given that it is a nine-item measure (Simard & Savard, 2009). Scores above 13 on the FCRI-SF suggest possible clinical levels, while scores above 22 indicate a need for intervention (Simard & Savard, 2009). In practice, it is important to help patients differentiate between normative FCR and distressing levels, addressing FCR at any stage. FCR is distinct from other mental health disorders, though it shares similarities with other diagnostic constructs in the DSM-V like illness anxiety disorder (Butow et al., 2018). It involves excessive worry about treatment-related side effects and a loss of trust in one’s health and one’s own body (Hall et al., 2019). Symptoms include intrusive thoughts, distressing emotions, and maladaptive behaviors like avoiding medical appointments or excessive reassurance-seeking (Hall et al., 2019; Luigjes-Huizer et al., 2022; Maheu et al., 2021). Survivors with FCR often seek more medical care, which can reinforce FCR and lead to unnecessary healthcare costs (Urquhart et al., 2025). Recognizing these features is essential for developing effective interventions for patients seeking therapy for these concerns.

Objective #2: Explain the Cognitive Processing Model of FCR

Fardell and colleagues (2016) completed a systematic review to better understand the conceptualization of FCR. Several theoretical models explain FCR, each with strengths and weaknesses. The Self-Regulation Model (SRM) suggests that FCR arises when cancer is seen as a persistent threat but doesn’t fully address emotional distress or cognitive biases. The Cognitive-Behavioral Model (CBM) focuses on maladaptive thoughts and behaviors but doesn’t explain why some individuals are more vulnerable to FCR. Attentional Bias Models highlight excessive monitoring of cancer-related stimuli but overlook other factors like social support. The Emotional Processing Model suggests unresolved emotional distress fuels FCR but doesn't address cognitive or behavioral patterns. The Self-Regulatory Executive Function (S-REF) Model and Intolerance of Uncertainty Model focus on beliefs about worry itself but miss key aspects like threat perception. An integrated approach that combines cognitive, emotional, and behavioral mechanisms with social factors is likely most effective in addressing FCR in clinical settings (Fardell et al., 2016).

Fardell and colleagues (2016) proposed the Cognitive Processing Model (CPM) for FCR to address gaps in the existing theories identified in their review. This model integrates insights from various frameworks, suggesting that individual vulnerabilities—such as past losses, stressful experiences, and lack of information—shape the cancer experience, leading to existential challenges. These challenges influence emotional, behavioral, and cognitive coping mechanisms, which can either promote normal adaptation or heighten FCR. In cases of normal adaptation, distress and intrusive thoughts about cancer decrease over time, and concerns about recurrence, while persistent, don’t dominate daily life. Emotional responses like anxiety lessen, and behavioral and cognitive responses, such as medical check-ups and intrusive thoughts, remain balanced. For those with heightened FCR, information processing becomes maladaptive, with excessive worry, self-focus, and frequent self-examination. This Cognitive-Attentional Syndrome (CAS) includes attempts to control or avoid thoughts of recurrence, paradoxically maintaining distress. Metacognitive beliefs, such as “worrying prepares me for recurrence,” further reinforce worry, leading to chronic anxiety, distress, and depression. Behavioral patterns like excessive symptom-checking, reassurance-seeking, and persistent intrusive thoughts impair daily life (Fardell et al., 2016). This model informs future research and interventions, highlighting targets for cognitive-behavioral therapy (CBT) and other evidence-based approaches to reduce worry, improve emotional regulation, and promote adaptive coping strategies in the face of FCR.

Objective #3: Identify Evidence-Based Psychotherapy Interventions for Treating FCR

To address vulnerability factors in the Cognitive Processing Model of Fear of Cancer Recurrence (FCR), evidence-based practices can reduce susceptibility to heightened FCR (Fardell et al., 2016). A key vulnerability is the lack of information on health monitoring after a cancer diagnosis, leading to confusion about checking behaviors (Fardell et al., 2016). Integrated care, particularly the Collaborative Care Model (CoCM), can be tailored to address this vulnerability factor in the context of FCR (Johns et al., 2020). CoCM involves a multidisciplinary team, including primary care providers and behavioral health specialists, to deliver comprehensive mental health care alongside medical treatment. It has proven effective for managing anxiety and depression in cancer patients and can be tailored to screen and treat FCR (Johns et al., 2020). Routine mental health screening, such as the Fear of Cancer Recurrence Inventory Short Form (FCRI-SF), helps detect FCR early. A behavioral health manager can coordinate care, provide interventions, and facilitate communication between providers. Patients showing severe avoidance or reassurance-seeking behaviors should be referred for further psychotherapy. Engaging patients in treatment planning, normalizing FCR, and reinforcing strategies for health control—like regular medical checkups and healthy behaviors—are vital in the application of CoCM to screening for, identifying, and addressing FCR utilizing integrated care (Johns et al., 2020).

As previously stated in the key factors of the Cognitive Processing Model of FCR, caregiving roles and other sources of psychological stress can significantly increase vulnerability to FCR (Fardell et al., 2016). Many cancer patients who live at home require assistance with activities of daily living, basic medical care, social needs, and patient advocacy (Fardell et al., 2016). Research demonstrates that caregiver support plays a crucial role in meeting these needs and contributes to improved health outcomes for the patient (Fardell et al., 2016). However, it is important to recognize that caregivers themselves are also at risk for developing and experiencing FCR (Berry, Dalwadi, and Jacobson, 2017). The emotional, physical, and mental toll of caregiving can heighten their own distress, making them equally susceptible to fears about the patient’s health and future (Sklenarova et al., 2015). Therefore, implementing evidence-based treatments for caregivers within the context of cancer care is essential (Smith et al., 2022). These interventions not only help caregivers manage their own FCR but also reduce the vulnerability of the cancer patient by fostering a more supportive and resilient caregiving environment. One valuable resource that addresses caregiver challenges is the Caring for the Caregiver booklet provided by the National Cancer Institute. This free resource offers guidance and support, helping caregivers navigate their role while prioritizing their own well-being. The booklet validates and normalizes the emotional experiences of caregivers, acknowledging the stress, fear, and uncertainty they often face. It also provides practical strategies for seeking help, including ways to delegate household tasks while focusing on the patient’s care. Suggestions include asking for assistance with errands, childcare, meal coordination, and communication with extended family and friends regarding treatment updates. Additionally, the booklet offers key questions caregivers can ask the medical team, as well as information on support groups and other community resources. By addressing these challenges, caregivers can buffer the impact of vulnerability factors through self-care and personal resilience (Fardell et al., 2016; Smith et al., 2022). This concept aligns with the well-known “airplane oxygen mask” metaphor—caregivers must take care of themselves first in order to provide the best care for their loved one. The strategies outlined in this resource serve as a foundation for promoting caregiver well-being and reducing FCR.

Meaning-Centered Psychotherapy (MCP) is another therapeutic approach designed to help individuals find or rediscover meaning and purpose, particularly in the face of suffering, illness, loss, or aging (Breitbart et al., 2010). It addresses another key factor of the CPM of FCR: the impact of cancer-related stressors, which can lead to existential challenges such as feelings of despair and disconnection from sources of meaning (Fardell et al., 2016). The MCP approach is rooted in Viktor Frankl’s logotherapy which describes the search for meaning as a fundamental human drive. By fostering a sense of purpose, MCP can enhance well-being, build resilience, and offer comfort in adversity, ultimately helping to reduce or buffer against FCR symptoms (Mozafari et al., 2018). MCP interventions focus on several key areas to help individuals reconnect with meaning in their lives (Breitbart et al., 2010). These include exploring personal sources of meaning, such as relationships, work, spiritual beliefs, or personal values, and reframing challenges in a way that allows for a sense of growth and purpose. Existential reflection encourages individuals to deeply consider life’s purpose, core values, and how they can live meaningfully in the present. Legacy building helps individuals focus on how they wish to be remembered or contribute to others: both hold potential to reinforce a sense of purpose. Spiritual exploration, regardless of religious affiliation, allows for a deeper understanding of life’s meaning, while mindfulness practices promote engagement with the present moment. Life reflection exercises, such as journaling or guided conversations, help individuals recognize and appreciate the meaning derived from significant life experiences. Through these interventions, MCP provides a structured approach to addressing existential concerns, fostering resilience, and mitigating the psychological distress associated with FCR (Breitbart et al., 2010; Mozafari et al., 2018).

In the context of heightened fear of cancer recurrence (FCR), individuals often exhibit maladaptive behavioral responses, such as excessive symptom checking, avoidance of cancer-related reminders, or frequent reassurance-seeking (Fardell et al., 2016). These behaviors can create a cycle that negatively reinforces anxiety and distress rather than alleviating them (Fardell et al., 2016). Emotionally, heightened FCR leads to persistent feelings of anxiety, distress, and even depression (Fardell et al., 2016). Several cognitive-behavioral therapy (CBT) techniques have been found to be effective in addressing these symptoms (Park & Lim, 2022). One such approach is adopting a response prevention mindset for reassurance-seeking behaviors. This involves understanding the reassurance-seeking cycle and implementing strategies such as cognitive refocusing or engaging in distractions when the urge arises to excessively check for symptoms or contact healthcare providers for reassurance. Behavioral activation is another useful intervention, particularly for combating depressive symptoms associated with heightened FCR, by encouraging engagement in meaningful and rewarding activities. Additionally, mindfulness-based approaches can help individuals develop a nonjudgmental acceptance of the natural emotions triggered by FCR while also creating space to challenge excessive or unhelpful worry (Hall et al., 2018). It is important to note that most research on CBT interventions for FCR has been conducted in the context of in-person, group treatment settings. However, these strategies anecdotally have been effective when utilized in one-on-one psychotherapy sessions by the current author, demonstrating their adaptability and usefulness in addressing the challenges associated with FCR.

Objective #4: Adapt and Apply Cognitive Restructuring to FCR in Psychotherapy

It is essential to recognize that FCR includes a very real and valid component—the realistic fear at the root of the worry given the person's prior lived experience (Butow et al., 2018). This presents a challenge when applying cognitive-behavioral therapy (CBT) interventions, such as cognitive restructuring, as the goal is not to dismiss or invalidate these fears but rather to help individuals manage them more effectively. To do so, cognitive techniques must be adapted to specifically target the underlying cognitive mechanisms that contribute to and maintain heightened FCR.

According to the CPM of FCR, these underlying cognitive mechanisms include a problematic style of information processing known as the cognitive-attentional syndrome (CAS), a construct first described by Adrian Wells, Ph.D. in Metacognitive Therapy (MCT: https://mct-institute.co.uk/) for anxiety and depression. Fardell and colleagues (2016) write about MCT applications for FCR, including phenomena of excessive worry, self-focused attention, and frequent self-examination. In an effort to manage their fears those with FCR may attempt to control, avoid, suppress, or minimize thoughts about recurrence (Fardell et al., 2016). However, these strategies are paradoxically counterproductive, as they serve to maintain and even amplify distress. A key factor in this cycle is also the presence of unhelpful metacognitions—beliefs about worry that reinforce and perpetuate anxiety (Fardell et al., 2016). Common examples include “If I worry about cancer coming back, I will be prepared,”“I cannot stop these thoughts. Worry thoughts cannot be controlled,” and “My worry will prevent recurrence.” By addressing these thought patterns while acknowledging the legitimacy of the fear itself, CBT interventions can help individuals develop healthier, more balanced ways of processing their concerns without becoming overwhelmed by them (Butow et al., 2018).

The goal of cognitive restructuring for FCR is to address the unhelpful cognitive mechanisms that contribute to or maintain heightened FCR without invalidating the legitimacy of the patient’s fears (Butow et al., 2018). The primary targets of this process include unhelpful beliefs about worry or metacognitions, rather than the FCR thoughts themselves. To effectively implement cognitive restructuring, it is crucial to consider a handful of adaptations. First, donot minimize the patient’s fears or attempt to provide reassurance based on their current health status (e.g., “Well, you’re in remission now, so everything will be okay!”). Additionally, donot directly challenge the accuracy of FCR thoughts, as this can invalidate the patient's experience and increase distress. Consider the use of validation as a therapeutic technique within sessions with patients endorsing FCR, drawing from principles in Dialectical Behavior Therapy (DBT). According to DBT, validation acknowledges and accepts a person’s emotions and behaviors, with six levels of validation guiding this approach (Linehan, 1987). In the context of FCR, levels four and five are particularly relevant: recognizing that a patient’s fear is understandable given their past experiences, learning history, or biological factors, and normalizing their feelings as a common response to their situation.

On the other hand, when utilizing the tool of cognitive restructuring for patients with FCR, clinicians do want to identify unhelpful beliefs about worry (metacognitions) that heighten FCR, and work on challenging these beliefs rather than the FCR worry thoughts themselves. For example, instead of focusing on whether FCR thoughts are true, encourage patients to reflect on whether the act of worrying is truly helpful or influencing their situation for the better in any way (“Does worry help, or is it my actions that prepare me?”). Help patients develop coping statements or alternative responses to use when unhelpful beliefs arise, such as “Worrying or ruminating does not minimize my chances of recurrence. What helps me is engaging in health-related behaviors, including…” Encourage patients to actively engage with these coping statements throughout the day by writing them down or reading them aloud when distressed.

Another key aspect to consider when adapting cognitive restructuring as a therapist working with patients endorsing FCR is the importance of promoting self-reliance. Do not enable patients to rely solely on external reassurance from providers or loved ones in an attempt to soothe their distress caused by FCR. Instead, empower patients to use emotion-focused coping strategies that help patients self-soothe and reduce their own experience of distress without trying to “problem solve” the worries away. Additionally, it is important to help patients recognize avoidance behaviors and build awareness of common triggers for acute increases in FCR thoughts so they can take a proactive approach to coping in situations where they are more likely to experience FCR thoughts arising. Encouraging increased engagement in values-based activities, a technique drawn from Meaning-Centered Psychotherapy (MCPT), Acceptance and Commitment Therapy (ACT), and DBT, can be a meaningful way to promote cognitive refocusing in the face of excessive worry. When patients are more aware of what can influence their own experience of FCR worry thoughts, they can be better equipped to proactively engage in self-soothing strategies, cognitive refocusing, or seeking social support to mitigate further increases in distress. Simple actions, such as calling a friend to ask about their day or volunteering to help someone else in a time of need, can shift attention away from excessive worry and promote emotional well-being. Through these techniques, patients can build resilience, develop effective coping mechanisms, and regain a sense of control over their fears.

In conclusion, Fear of Cancer Recurrence (FCR) poses significant challenges for cancer survivors and caregivers, impacting psychological well-being and functioning. Understanding FCR’s cognitive, emotional, and behavioral aspects is essential for effective interventions. The CPM offers valuable insight into how vulnerabilities and maladaptive coping mechanisms contribute to heightened FCR (Fardell et al., 2016). Evidence-based treatments, such as CBT, mindfulness, and MCP, provide pathways to alleviate distress. A holistic approach that validates the patient’s experience while equipping them with adaptive coping strategies is crucial. Support for caregivers is equally important, as their well-being directly impacts the patient’s recovery. By fostering resilience and adaptive coping, we can improve the quality of life for those navigating FCR.

References

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Breitbart, W., Rosenfeld, B., Gibson, C., Pessin, H., Poppito, S., Nelson, C., et al. (2010). Meaning-centered group psychotherapy for patients with advanced cancer: A pilot randomized controlled trial. Psycho-Oncology, 19(1), 21–28. https://doi.org/10.1002/pon.1621

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Fardell, J. E., Thewes, B., Turner, J., Gilchrist, J., Sharpe, L., Smith, A., Girgis, A., & Butow, P. (2016). Fear of cancer recurrence: A theoretical review and novel cognitive processing formulation. Journal of Cancer Survivorship, 10(4), 663–673. https://doi.org/10.1007/s11764-015-0512-5

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Linehan, M. M. (1987). Dialectical behavior therapy for borderline personality disorder: Theory and method. Bulletin of the Menninger Clinic, 51(3), 261.

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Maheu, C., Singh, M., Tock, W. L., Eyrenci, A., Galica, J., Hébert, M., Frati, F., & Estapé, T. (2021). Fear of cancer recurrence, health anxiety, worry, and uncertainty: A scoping review about their conceptualization and measurement within breast cancer survivorship research. Frontiers in Psychology, 12, 644932. https://doi.org/10.3389/fpsyg.2021.644932

Mozafari, S., Rahimian Boogar, I., Talepasand, S., & Ghahreman Fard, F. (2018). Effectiveness of Meaning-Centered Psychotherapy on existential anxiety and fear of cancer recurrence in breast cancer survivors: A randomized clinical trial. Women’s Health Bulletin, 5(1), 1–7. https://doi.org/10.5812/whb.13917

Park, S. Y., & Lim, J. W. (2022). Cognitive behavioral therapy for reducing fear of cancer recurrence among breast cancer survivors: A systematic review of the literature. BMC Cancer, 22, 217. https://doi.org/10.1186/s12885-021-08909-y

Simard, S., & Savard, J. (2009). Fear of cancer recurrence inventory: Development and initial validation of a multidimensional measure of fear of cancer recurrence. Supportive Care in Cancer, 17(3), 241–251. https://doi.org/10.1007/s00520-008-0444-y

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Prolonged Exposure Therapy for Adolescents with PTSD: A Review of Emotional Processing Theory and the Evidence To Date

Mon, 19 May 2025 13:39:44 GMT

Sandy Capaldi, PsyD - Center for the Treatment and Study of Anxiety

Excerpted and adapted from Capaldi, S., & Foa, E. B. (2025). Prolonged exposure therapy for adolescents with PTSD: emotional processing of traumatic experiences. In Evidence-Based Treatments for Trauma-Related Disorders in Children and Adolescents (pp. 271-290). Cham: Springer Nature Switzerland.

Prolonged Exposure therapy for adolescents with PTSD (PE-A; Foa et al. 2008) is an adaptation of the widely studied, empirically validated adult Prolonged Exposure (PE) protocol (Foa et al. 2019). Developed for and tested with adolescents ages 12-18, PE-A is a manualized, symptom-focused treatment designed to target PTSD symptoms in the aftermath of all types of trauma. The treatment consists of four key phases: pretreatment preparation, psychoeducation and treatment planning, exposures, and relapse prevention/treatment termination. Each phase is comprised of several modules that emphasize a specific therapeutic task or goal. While PE-A is delivered in an individual format, it remains flexible, allowing for the inclusion of parents or caregivers in portions of sessions. The structure accommodates varying session lengths and pacing, ensuring adaptability to the developmental needs of each adolescent. The typical course of treatment occurs over 10–15 weekly sessions lasting 60-90 minutes each.

Emotional Processing Theory

The treatment is grounded in cognitive-behavioral therapy and learning theory. Drawing from classical and operant conditioning paradigms, the theory behind PE was influenced by Mowrer's two-factor model of avoidance (Mowrer, 1960). In Mowrer’s model, fear is initially acquired through classical conditioning, reinforced through avoidance, and maintained through operant conditioning. Expanding on these ideas, Foa and Kozak (1986; Foa et al. 2006) integrated Lang’s (Lang, 1977) concept of fear structures, developing what has become known as emotional processing theory (EPT). EPT provides a framework for understanding the factors that contribute to the development and maintenance of post-traumatic stress symptoms, the mechanisms underlying natural recovery from these symptoms, and the amelioration of these symptoms via exposure treatments. EPT proposes that emotions like fear are represented in memory as an emotional structure which serves as a blueprint for action. This structure consists of three core elements: representations of the feared stimuli, corresponding fear responses, and the meanings associated with the stimuli and the responses. A fear structure becomes maladaptive when it incorporates inaccurate or exaggerated associations between the meanings associated with the stimuli and responses, leading to fear responses to harmless stimuli. For example, an adolescent who was bitten by a dog might generalize this fear to all dogs, avoiding them completely—even friendly ones—because they believe any dog poses a threat.

According to EPT, traumatic memories are structured emotional representations that encode the stimuli present during the trauma, the individual's emotional and physiological responses (e.g., fear, guilt, shame, freezing), and the meanings attributed to those experiences. In PTSD, the trauma memory contains an excessive number of stimuli erroneously linked to danger. For example, an adolescent who was sexually assaulted may associate related but harmless stimuli, such as men with similar builds as the perpetrator or small, enclosed spaces, with the meaning of danger. As a result, individuals with PTSD are likely to perceive the world as entirely dangerous. In addition, representations of the individuals’ responses during and following the trauma often become associated with the meaning of incompetence (e.g., “I failed to protect my friend”; “My PTSD symptoms mean I am weak”). These two perceptions – that the world is entirely dangerous and the person is very incompetent – serve to maintain PTSD symptoms.

PTSD symptoms often emerge immediately after a traumatic event, but for many individuals, these symptoms naturally diminish over time without intervention. EPT suggests that natural recovery occurs through repeated exposure to trauma-related memories, emotions, and situations in daily life. Engaging with these reminders—whether by discussing the trauma, reflecting on associated emotions, or encountering related environments—provide information that disconfirms the perception that the feared stimulus is dangerous. For individuals who develop PTSD, however, avoidance of trauma-related thoughts, feelings, and situations impedes activation of the trauma memory and integration of disconfirming information that would alter the pathological elements in the fear structure. To counteract this, treatment is designed to approach the safe but feared situations to allow the opportunity to experience the absence of negative consequences, which reduces or eliminates the two perceptions that help to maintain PTSD symptoms – that the world is entirely dangerous and the person is very incompetent.

For example, if an adolescent girl who experienced a vicious dog attack avoids all dogs, she never learns that most dogs she might encounter are actually safe. Additionally, by avoiding thinking about what happened, this adolescent’s memory will often remain fragmented and poorly articulated, and the erroneous perception that she may have been responsible for the attack will remain unquestioned. The adolescent’s avoidance behaviors are negatively reinforced because they temporarily reduce distress and so become habitual in similar circumstances. If she sees a dog approaching her on the street and quickly crosses to the other side, she experiences immediate relief. If she begins to think about the attack, becoming highly distressed, and immediately pushes those thoughts away or tries to distract herself, she may also experience relatively quick relief. However, while avoidance reduces distress in the short term, it perpetuates PTSD by blocking experiences that would otherwise modify the pathological elements in the fear structure. In our example, this adolescent girl does not get the opportunity to learn that the dog could have been safe (because she avoided it) or to learn that she is not to blame for the attack (because she does not allow herself to think about it).

Learning about the relative safety of trauma-related situations and memories and the relative competence of the individual who experienced the trauma is achieved for many individuals who do not develop PTSD through natural recovery. In essence, natural recovery includes approaching trauma-related triggers in daily life so that learning can occur. Effective PTSD treatment modifies the pathological elements of the fear structure and reduces pathological reactions by simulating natural recovery. In order to achieve this, two conditions are necessary. First, the fear structure must be activated (i.e., feared stimuli must be approached). Second, new information that is incompatible with the unrealistic elements (i.e., the feared stimuli is not dangerous) must be available and incorporated. When this new learning (or emotional processing) takes place, stimuli that used to evoke pathological responses will no longer do so.

PE-A aims to promote emotional processing by encouraging adolescents to talk about the trauma, referred to as revisiting and recounting the trauma memory (imaginal exposure), and to approach objectively safe situations that are trauma reminders, referred to as real-life experiments (in vivo exposure). By deliberately confronting safe but avoided trauma-related thoughts, feelings, and situations, the pathological fear structure is activated, and erroneous elements are modified through corrective experiences. Repeatedly recounting the traumatic memory reduces the anxiety associated with thinking about the trauma, provides opportunities to organize and better understand what happened, and helps the adolescent to explore and disconfirm other erroneous perceptions (e.g., that the adolescent’s actions mean he/she is incompetent or at fault for the trauma). Confronting trauma reminders and situations that are erroneously perceived as dangerous via real-life experiments reduces PTSD symptoms by breaking the habit of avoidance, promoting recognition that these situations are not harmful, and increasing the adolescent’s confidence in his or her ability to cope.

Research Evidence

Research on Prolonged Exposure Therapy for Adolescents (PE-A) has demonstrated its effectiveness in treating PTSD and superiority to active comparison treatments in multiple randomized controlled trails (RCTs).

PE-A vs. Time-Limited Dynamic Psychotherapy (TLDP): In Gilboa-Schechtman et al.’s (2010) RCT, adolescents (ages 12–18) with PTSD stemming from a single-event trauma (n = 38) were randomized to receive either PE-A or TLDP. Results showed that 73.7% of PE-A participants achieved good end-state functioning compared to 31.6% in TLDP. Furthermore, 68.4% of adolescents in the PE-A group no longer met criteria for PTSD post-treatment, compared to 36.8% in TLDP. These improvements were sustained at 6- and 17-month follow-ups.
PE-A vs. Client-Centered Therapy (CCT): This RCT (Foa et al., 2013) assessed adolescent females (ages 13–18) with PTSD related to sexual abuse (n = 61) who sought treatment in a community mental health setting. PE-A led to greater reductions in PTSD and depression symptoms, as well as enhanced global functioning compared to CCT. At post-treatment, 83.3% of adolescents receiving PE-A no longer met PTSD criteria, versus 54% in the CCT group. These gains persisted at 12-month follow-up.
PE-A vs. Supportive Counseling (Delivered by Psychotherapy-Naïve Nurses): In this RCT, Roussouw et al. (2018) examined PE-A’s effectiveness among adolescents (ages 13–18) with chronic PTSD due to interpersonal trauma (n = 63) in South African schools. The PE-A group showed more significant PTSD and depression symptom reductions and improved global functioning compared to those receiving supportive counseling. By post-treatment, 80% of PE-A participants no longer met PTSD criteria, compared to 48% in the counseling group. These results remained stable at 12- and 24-month follow-ups (Roussouw et al., 2022). Notably, this study demonstrated that psychotherapy-naïve nurses could successfully deliver PE-A with fidelity, reinforcing its potential for broad implementation, particularly in low- and middle-income countries.
Impact on behavioral symptoms & suicidal ideation: Utilizing data from Foa et al. (2013), Zandberg et al. (2016) found that adolescents treated with PE-A exhibited greater reductions in externalizing symptoms, including rule-breaking, aggression, and conduct problems, compared to those receiving Client-Centered Therapy (CCT). Additionally, Brown et al. (2020) observed that suicidal ideation decreased more rapidly in adolescents who underwent PE-A than in those randomized to CCT.
Therapeutic alliance and treatment outcomes in PE-A: Process-focused research has highlighted the importance of therapeutic alliance in PTSD recovery. Capaldi et al. (2016) analyzed data from Foa et al. (2013) and found that adolescent-rated alliance improved more in PE-A than in CCT, with stronger alliance associated with better treatment outcomes across both therapies. These findings challenge concerns that exposure-based interventions might disrupt therapeutic relationships, demonstrating that symptom-focused trauma work can enhance alliance rather than hinder it.
Mechanisms of change in PE-A: Studies examining the underlying processes in PE-A suggest that modifications in trauma-related cognitions play a central role in symptom relief. McLean et al. (2015) found that changes in negative trauma-related beliefs mediated reductions in both PTSD and depression symptoms. Later research (McLean et al., 2017) reinforced this connection, showing that PTSD symptom reductions during PE-A led to subsequent decreases in depressive symptoms.
Exploratory research on “intensive” PE-A:

Hendriks et al. (2017) examined a five-day intensive PE-A program for adolescents (ages 12–18) with PTSD and comorbid disorders stemming from multiple interpersonal traumas. The model consisted of 15 PE-A sessions in five days, followed by three weekly booster sessions. Findings indicated significant reductions in PTSD, depression, anxiety, and dissociation symptoms from pre- to post-treatment, with no dropouts or adverse events, suggesting potential benefits for treatment retention.
Tijsseling et al. (2024) conducted a trial examining an intensive PE-A format that included four half days of treatment per week for two weeks and included 90 minutes of PE-A and 90 minutes of EMDR each day. Results indicated PTSD remission rates of 58%–62% and decreases in PTSD severity compared with baseline, with treatment effects maintained at 1-month and 3-month follow-ups and a dropout rate of 13%.
Rentinck et al. (2025) investigated an intensive treatment format that consisted of six treatment days, divided into three treatment days per week, for two consecutive weeks and included 90 minutes of PE-A and 90 minutes of EMDR each day. Findings showed a significant reduction in PTSD symptoms (Cohen’s d = 1.66) and depressive symptoms (Cohen’s d = 1.02) from pre-treatment to one month after treatment, with 70% (n=52) showing a clinically meaningful response, and 65% (n=48) no longer meet the PTSD criteria one month after treatment. Dropout was 4% (N = 3) and no adverse events or worsening of symptoms were observed.

These findings underscore PE-A’s effectiveness and adaptability across different populations and settings, making it a vital evidence-based intervention for adolescents with PTSD. Research on PE-A has expanded beyond its core effectiveness to examine secondary outcomes and treatment processes as well.

While existing studies support PE-A as an effective intervention, further research is warranted to refine its implementation. Larger-scale randomized clinical trials comparing PE-A with other evidence-based PTSD treatments in adolescents are needed. Future research should also explore cultural adaptations, mechanisms driving symptom change, and predictors of treatment success and failure to optimize outcomes. Although additional studies are necessary, current evidence strongly supports PE-A as a first-line treatment for adolescent PTSD

Brown LA, Belli G, Suzuki N, Capaldi S, & Foa EB. (2020). Reduction in suicidal ideation from prolonged exposure therapy for adolescents. Journal of Clinical Child & Adolescent Psychology, 49(5), 651-659. https://doi.org/10.1080/15374416.2019.1614003

Foa EB, Chrestman K, & Gilboa-Schechtman E. (2008) Prolonged exposure therapy for adolescents with PTSD: Emotional processing of traumatic experiences. Oxford University Press.

Foa EB, Hembree EA, Rothbaum BO, & Rauch, S. (2019). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences - therapist guide, 2nd edition. Oxford University Press.

Foa EB, Huppert JD, & Cahill SP. (2006). Emotional processing theory: an update. In: Rothbaum BO (ed) Pathological anxiety: emotional processing in etiology and treatment (pp. 3–24). Guilford Press.

Foa EB & Kozak MJ. (1986). Emotional processing of fear: exposure of corrective information. Psychological Bulletin, 99, 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Foa EB, McLean CP, Capaldi S, & Rosenfield D. (2013). Prolonged exposure vs. supportive counseling for sexual abuse-related PTSD in adolescent girls: a randomized controlled trial. JAMA, 310, 2650–2657. https://doi.org/10.1001/jama.2013.282829

Gilboa-Schechtman E, Foa EB, Shafran N, Aderka IM, Powers MB, Rachamim L, Rosenbach L, Yadin E, & Apter A. (2010). Prolonged exposure versus dynamic therapy for adolescent PTSD: a pilot randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 49, 1034–1042. https://doi.org/10.1016/j.jaac.2010.07.014

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McLean, CP, Su, Y, Carpenter, JK, & Foa, EB. (2017). Changes in PTSD and depression during prolonged exposure and client-centered therapy for PTSD in adolescents. Journal of Clinical Child & Adolescent Psychology, 46(4), 500-510, https://doi.org/10.1080/15374416.2015.1012722

McLean, CP, Yeh, R, Rosenfield, D, & Foa, EB, Changes in negative cognitions mediate PTSD symptom reductions during client-centered therapy and prolonged exposure for adolescents, Behaviour Research and Therapy, 68, 64-69. https://doi.org/10.1016/j.brat.2015.03.008

Mowrer, OH. (1960). Learning theory and behavior. John Wiley & Sons Inc. https://doi.org/10.1037/10802-000

Rentinck, E. M., van Mourik, R., de Jongh, A., & Matthijssen, S. J. M. A. (2025). Effectiveness of an intensive outpatient treatment programme combining prolonged exposure and EMDR therapy for adolescents and young adults with PTSD in a naturalistic setting. European Journal of Psychotraumatology, 16(1). https://doi.org/10.1080/20008066.2025.2451478

Rossouw, J., Yadin, E., Alexander, D., & Seedat, S. (2018). Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: Task-shifting randomised controlled trial. The British Journal of Psychiatry, 213(4), 587-594. https://doi.org/10.1192/bjp.2018.130

Rossouw, Yadin, E., Alexander, D., & Seedat, S. (2022). Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: a task-shifted intervention. Psychological Medicine., 52(6), 1022–1030. https://doi.org/10.1017/S0033291720002731

Tijsseling, I., Noordende, A. T. V. T., Zijlstra, B. J., Merbis, M., & Veen, S. C. V. (2024). The Effectiveness and Tolerability of an Intensive Outpatient Trauma Treatment Program for Adolescents With PTSD. Journal of EMDR Practice and Research, 18(2), 68-81.

Zandberg, L, Kaczkurkin, AN, McLean, CP, Rescorla, L, Yadin, E, & Foa, EB. (2016). Treatment of adolescent PTSD: The impact of prolonged exposure versus client-centered therapy on co-occurring emotional and behavioral problems. Journal of Traumatic Stress, 29(6), 507–514. https://doi.org/10.1002/jts.22138

A Life Well-Lived: The Three Keys of Awareness, Attitude, and Values

Mon, 28 Oct 2024 17:30:49 GMT

William Kuyken, PhD - University of Oxford

Hiking in the Lake District of England, I stopped for lunch in a cemetery. There was a headstone with a name and this simple inscription: “A Life Well Lived.” What does a life well lived look like? It’s a question that we’ve all asked in one form or another. It’s been a question that has been asked for millennia by artists, from musicians, painters, dancers, sculptors to rappers, philosophers, contemplatives, and poets. What does mindfulness have to do with this?

Mindfulness: Three Keys to Living Well

Mindfulness offers three keys that can help unlock a life well lived (Feldman & Kuyken, 2019).

Key 1: Befriending Your Mind

“My mind can be my worst enemy or best friend," said Raheem Sterling, a young English soccer player. Sterling is known for inspiring others through his work ethic, for his family values, and for raising awareness of important social issues. He meditates because it helps him befriend his mind, which in turn helps him with his sport, mental health, and wider work.

What does friendship mean to you? What words or phrases best describe your friendships? What does a good friend do for you—now and over years, through the good and the bad patches of your life?

I’ve posed these questions to hundreds of people in workshops around the world, and here is what people said most often.

“Mindfulness is about our mind being and becoming our best friend.”

Does your idea of a good friend describe how you feel about your own mind? Maybe you already talk to yourself in affirming ways, with messages like “You’ve got this,” Steady,” “Take a breath,” “I’ve got your back; it will be okay.” Or maybe the voice you use with yourself is critical--“I can’t do that”--or demanding: “I don’t have time.” If you already have a sense of your mind as a friend, you can always develop that friendship further. You can choose to befriend your mind, so it becomes as practiced and natural as putting on your shoes before you go out. If you don’t feel like your mind is your friend, you’ll learn in the following pages how to change that, whatever challenges it throws up and amid whatever life circumstances you’re in.

Key 2: Using Your Values as Your Compass

Certain ideas and values have become mainstream:

I measure myself by how much I get done, what I'm bringing in, whether it's on a personal level or for the greater good, sort of like my "Gross Domestic Product.”
I put myself first because it is a dog-eat-dog world.I've got to always be on point – you know, look amazing, stay youthful, stay in shape, be attractive, and show that I'm making it in life.
If I let my guard down, I’ll get taken advantage of.
Busyness is good.
Being tough is good; being kind is soft.
Being in the spotlight, that's what gives my life meaning. I'm this close to striking it rich, if only I can score the perfect job, hit that jackpot, blow up as an influencer, or just start hanging with the right crowd.

From an early age, we feel pressure to have an opinion--about who we are, other people, what we like and don’t like, our favorite this or that, what we want to do when we grow up. We may claim certain “values” just to avoid uncertainty or to avoid feeling ashamed of not knowing what our values are. With all the pressure on us to do well, be better, achieve, prove we deserve our place in the world, or look a certain way, we may simply adopt prevalent ideas without question. When we do, we may end up pursuing someone else’s vision for our life. Of course productivity is necessary, but few people at the end of their lives look back and say, “I had a good life because I was productive and successful in this dog-eat-dog, getting-ahead world.” And if they do, did it make them and the people around them happy? Ask yourself right now what makes you happy. What or whom do you care most about? What are you passionate about? No need to overthink, just note what comes up, then let it go and see what else comes up. And don’t worry if not much arises; that’s fine too.

Your answers to these questions of what matters most point to your values. We’re all different, and an important part of living well is knowing what’s meaningful to us.

Here are some of the values that people often mention.

Wherever you are, whatever you’re doing, your values, like a compass, point you in the right direction.

Values are at the root of mindfulness; they guide how we are in the world and what we say and do. And just as important, they guide what we don’t say or do. If family is a foundational value, this shapes choices and even lives. Faith provides a set of values that can provide a sense of belonging and meaning. Everyone’s story involves learning a set of values. My father has a strong work and family ethic, developed in very difficult circumstances when he found himself the “man of the family” as a young boy interned in a concentration camp with his mother and younger sisters and brother. Throughout his life he provided selflessly for his family through hard work. I know he regarded the savings he left behind to provide for my mother and my sisters and me a key part of his life work.

These three keys of mindfulness together bring to life how your values can be your sense of direction, your compass, the route map on your phone. Your role is to explore your values and how they can guide you. To embrace your values and be courageous enough to value what is truly important. The landscape of our lives, our family, our school, workplace, community, planet is created by human minds and hearts. It can be tempting to retreat to routine, to where we feel safe, to what we know. But try asking, “Is this enlarging and in line with my values or reassuring but ultimately diminishing?” Enlarge your mind, your relationships, your life, your sense of what is possible in the world. Seek out what enlarges you, whatever that is. It may be people in your life, sport, art, a favorite phrase, or an idea. Who and what enlarges you? Can they be what protects you, vitalizes you, and gives you a sense of purpose?

Key 3: Waking Up and Paying Attention

There are a lot of pulls on our attention, and this can give us a sense of being fragmented. With all the demands on us, it’s easy to react by checking out and sleepwalking through life. Zoning out can be comfortable, but there are many good reasons to live with a sense of being fully awake.

Leading the life we want means waking up and paying attention.

Attention is one of your most important resources (McGilchrist, 2023). What you focus on shapes what you think, your decisions, what you feel, and ultimately, your reality. It's like the spotlight that illuminates certain conversations, people, successes, problems, feelings, while leaving others in the shadows (Jha et al., 2007). How much of today have you been awake? I don’t mean awake literally; I mean awake in the sense of feeling alive. Twenty-five percent, 50 percent, most of the day? In the pages ahead you’ll find ways you can learn to pay attention to how you spend your days - and the moments of each day. Every moment is already here, waiting for you to pay attention to it. In a sense you don’t need to do anything differently. It is more of an adjustment in how you approach your day, choosing to pay attention, on purpose, with attitudes of curiosity and friendliness.

When you’re guided by your values, you befriend your mind, and you live with awareness, you focus on what matters, and your deepest values and daily life come together in a way that feels whole. Vulnerability can align with strength, kindness can be a force for positive change, compassion can be tough, and love can seep into and out from the people in your life.

Extracted from my 2024 book Mindfulness for Life (Kuyken, 2024): The Mindfulness for Life curriculum (Kuyken, 2024), is based on ancient wisdom, modern psychology (Feldman & Kuyken, 2019) and the essential structure of mindfulness-based stress reduction (Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (Segal et al., 2013; Teasdale et al., 2003).

Feldman, C., & Kuyken, W. (2019). Mindfulness: Ancient wisdom meets modern psychology. Guilford.

Jha, A. P., Krompinger, J., & Baime, M. J. (2007). Mindfulness training modifies subsystems of attention [Article]. Cognitive Affective & Behavioral Neuroscience, 7(2), 109-119. https://doi.org/10.3758/cabn.7.2.109

Kabat-Zinn, J. (1990). Full catastrophe living: how to cope with stress, pain and illness using mindfulness meditation. Delacorte.

Kuyken, W. (2024). Mindfulness for Life. Guilford Press.

McGilchrist, I. (2023). The Matter With Things: Our Brains, Our Delusions, and the Unmaking of the World. Perspectiva.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression. (Second edition ed.). Guilford Press.

Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (2003). Mindfulness training and problem formulation. Clinical Psychology-Science and Practice, 10(2), 157-160. https://doi.org/Doi 10.1093/Clipsy/Bpg017

The Extreme Demands of Family Caregiving

Mon, 28 Oct 2024 17:18:07 GMT

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

“Anger is completely normal” – Emotion regulation and stress management for family caregivers of people with dementia

The extreme demands of family caregiving

People who care for a family member with dementia face an abundance of complex, challenging, and time-consuming demands. Caregivers support care recipients with the activities of daily life (e.g., household management; assistance with food and fluid intake; personal hygiene, especially for incontinence; visiting public authorities, attending doctor visits). Caregivers also work to provide a supportive socioemotional context for the care recipient through, for example, conversation and activities. Caregivers also manage the behavioral and psychological symptoms of dementia, such as orientation disorders, confusion, self-threatening behavior, or personality changes. Caregivers often find managing the behavioral and psychological symptoms especially challenging; the care recipient’s behavioral and psychological symptoms are stronger predictors of the caregiver’s well-being and institutionalization of the care recipient than the care recipient’s functional or cognitive impairments, the number of caregiving tasks, or duration of care (Coen et al., 2002; Perren et al., 2006).

The challenges of caring for a family member with dementia are often compounded by number of factors. For instance, caregiving tasks are constantly evolving as the person’s dementia progresses. Caregivers are often working or taking care of their children at the same time that they are providing care. Sleep deprivation, social isolation, lack of leisure time, and loss of personal freedom can further increase stress. Given these multifaceted demands and constraints, it is unsurprising that family caregivers are more likely to experience depressive symptoms and anxiety (Collins & Kishita, 2020; Kaddour & Kishita, 2020), lower quality of life (Kurz & Wilz, 2011), and physical morbidity (Cheng et al., 2017) than their non-caregiving peers.

Anger, rage, and aggression

Family caregivers sometimes react to the extreme demands of caregiving with anger, rage and unintentional aggression. The experience of such strong, negative emotions and impulses can set a vicious cycle in motion. Caregivers feel ashamed or guilty, especially when they have acted out aggressively toward the person with dementia. They reproach themselves for their emotions and lack of self-control. They may feel depressed or anxious about their ability to control their own impulses, doubt their caregiving competence, and ultimately lose self-esteem. The negative feelings and self-blame add to the burden of caregiving, thereby increasing the likelihood that the caregiver will react to challenging situations with anger, rage and aggression.

Caregivers’ anger and subsequent self-reproach can also have serious negative consequences for care recipients. Highly-burdened family caregivers and family caregivers who doubt their competence are more likely to act abusively toward the care recipient (Fang et al., 2019; Karrasch, 2008; Välimäki et al., 2020; Konopik et al., 2022; Sasaki et al., 2007; Stall et al., 2019). In fact, elder abuse and especially psychological violence (typically unintended) frequently occur in high-burden informal caregiving situations. About 5% of caregivers report at least one incidence of physical violence (e.g., shaking or hitting the care recipient); far more report losing patience or lashing out verbally.

In light of its negative impact on caregivers as well as care recipients, addressing anger should be an integral part of psychotherapy with family caregivers (Wilz, 2024). Specifically, therapists and caregivers should work together to reduce caregivers’ anger and impulsive reactions, but also foster caregivers’ acceptance of burdensome emotions in situations that cannot be changed.

Psychotherapeutic strategies for reducing anger, improving emotion regulation, and fostering acceptance

An important aspect of working with family caregivers is de-pathologizing anger and aggressive impulses. Clarifying that it is normal to experience negative emotions and impulses in challenging, stressful situations usually has an immediate, alleviating effect. Family caregivers are relieved to learn that other family caregivers have similar emotions and impulses. Family caregivers should have the opportunity to openly discuss incidences of aggression. Therapists should communicate that aggression is understandable, but also clearly undesirable and avoidable. Family caregivers should be encouraged to reflect on how aggressive reactions can be prevented in the future.

Often family caregivers do not know what to do with their negative emotions; they lack an outlet for their anger. Caregivers should therefore be encouraged to vent and act out their anger in therapy sessions. Crying, screaming, or physical exercises can relieve tension and help caregivers manage stress. It should be noted, however, that this “acting out” of anger should not occur in the presence of the care recipient, as people with dementia can be overwhelmed by the expression of strong negative emotions.

The therapist and family caregiver should also work together to develop strategies to defuse acute feelings of anger. Being able to distance themselves from their emotions can help caregivers analyze a situation more clearly. The therapist and family caregiver should therefore identify how the individual caregiver can distance themselves and “cool down” in acute problem situations (e.g., leaving the room, going for a walk) (Kaluza, 2015). The therapist and caregiver then analyze the extent to which specific problem situations could be improved. Caregivers must have a degree of emotional detachment in order to make this decision. Behavior and situation analyses can be used to analyze the highly stressful situation in more detail and find out strategies for dealing with them constructively. When the caregiver recognizes that it would be possible to improve the situation, the therapist can use problem-solving training to identify and assess potential courses of action.

Some stressful aspects of the caregiving situation cannot be changed, such as the care recipient’s recurring challenging behavior. Therapeutic work should thus not only to address how the caregiving situation could be improved, but also foster caregivers’ acceptance of negative thoughts and emotions in situations that cannot be changed. Here acceptance means perceiving and experiencing negative thoughts and feelings without trying to change or avoid them. There is robust empirical evidence that trying to avoid negative emotions is counterproductive. Research has shown, for instance, that suppressing negative emotions is associated with lower well-being, lower interpersonal functioning, and lower positive affect (Gross & John, 2003). Caregivers who tend to deny or avoid their negative emotions have higher levels of emotional distress (Spira et al, 2007) and higher mean arterial pressure (an indicator of physiological stress; Losada et al., 2014). In contrast, family caregivers of people with dementia with more functional thoughts regarding acceptance have lower depression, anxiety, and grief, and higher psychological quality of life (Risch et al., 2022; Wrede et al., 2024). Working with caregivers to improve their acceptance of negative emotions that cannot be changed can therefore help them maintain their health and well-being. Strategies from acceptance and commitment therapy (e.g., Hayes et al., 2008) are particularly helpful for decreasing caregivers’ experiential avoidance, that is, the tendency to avoid unchangeable aversive emotions, sensations or thoughts (Risch et al., 2024).

Finally, therapists and caregivers should work together to reduce the caregiver’s general level of tension. Relaxation exercises and addressing how the caregiver can pursue valued activities within the constraints of the caregiving situation can help caregivers to reduce stress over the long-term, and thereby lessen the likelihood of anger, rage and impulsive reactions.

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Psychotherapy with Family Caregivers: Addressing Dysfunctional and Functional Thoughts

Tue, 26 Mar 2024 18:14:07 GMT

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.

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Telehealth Strategies for CBT with Older Adults

Wed, 28 Feb 2024 18:42:32 GMT

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; www.pltcweb.org).

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. https://doi.org/10.1037/cps0000056

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. https://doi-org.ezproxy.umsl.edu/10.1016/j.cbpra.2015.03.001

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. https://doi.org/10.1037/int0000121

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.

Using Mindfulness-Based Therapy to Address Low Sexual Desire in Women

Thu, 21 Dec 2023 17:43:24 GMT

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).

lack of interest (or no interest) in sexual activity;
reduced or absent erotic thoughts or fantasies;
reduced level of initiating sex and/or responding to a partner’s sexual advances;
reduced pleasure during sexual activity;
lack of responsive sexual desire (i.e., desire that emerges with or after sexual arousal); and
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., 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 Research, 60(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.

Managing Therapeutic Alliance Ruptures in Cognitive-Behavioral Therapy

Wed, 29 Nov 2023 17:15:58 GMT

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

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.
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.
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.
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

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.
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).
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.
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. https://doi.org/10.1037/a0033171.

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. https://doi.org/10.1016/j.cbpra.2022.02.012

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. https://doi.org/10.1037/pst0000469.

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

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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. https://doi.org/10.1037/0022-006x.74.2.337

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

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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.

Using Acceptance and Commitment Therapy to Guide Exposure

Mon, 16 Oct 2023 13:00:57 GMT

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 Therapy, 48(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 Therapy, 46, 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 psychology, 82(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 Psychiatry, 20(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 (2^nd 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 Science, 24, 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 & Psychotherapy, 24(3), 697-711.

Thompson, B.L., Luoma, J.B., & LeJeune, J.T. (2013). Using acceptance and commitment therapy to guide exposure-based interventions for posttraumatic stress disorder. Journal of Contemporary Psychotherapy, 43, 133-140.

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 Therapy, 52(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.

A Primer for Training Savoring Skills in Psychotherapy (Part 2): Core Procedures and Exercises

Sun, 08 Oct 2023 20:31:02 GMT

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. https://doi.org/10.1037/ccp0000396

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. https://doi.org/10.1016/j.isci.2022.105718

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. https://doi.org/10.1007/s12671-017-0704-3

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. https://doi.org/10.1016/j.janxdis.2022.102659

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. https://doi.org/10.1037/ccp0000794

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. https://doi.org/10.3389/fpsyg.2018.00763

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. https://doi.org/10.1016/j.janxdis.2023.102724

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. https://doi.org/10.1002/jclp.20593

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. https://doi.org/10.1111/psyp.13754

A Primer for Training Savoring Skills in Psychotherapy (Part 1): Foundational Concepts

Fri, 25 Aug 2023 11:59:41 GMT

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. https://doi.org/10.1186/1471-2458-13-119

Bryant, F. B. (2003). Savoring beliefs inventory (SBI): A scale for measuring beliefs about savoring. Journal of Mental Health, 12(2), 175-196. https://doi.org/10.1080/0963823031000103489

Catalino, L. I., Algoe, S. B., & Fredrickson, B. L. (2014). Prioritizing positivity: An effective approach to pursuing happiness? Emotion, 14(6), 1155-1161. https://doi.org/10.1037/a0038029

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. https://doi.org/10.1037/hea0000763

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. https://doi.org/10.1016/j.jbtep.2019.101525

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. https://doi.org/10.1007/s10608-020-10202-4

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. https://doi.org/10.1023/A:1010796329158

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. https://doi.org/10.1016/j.cpr.2010.03.002

Gloria, C. T., & Steinhardt, M. A. (2016). Relationships among positive emotions, coping, resilience and mental health. Stress & Health, 32(2), 145-156. https://doi.org/10.1002/smi.2589

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. https://doi.org/10.1080/17439760.2012.671345

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. https://doi.org/10.1007/s12671-017-0704-3

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. https://doi.org/10.1016/j.paid.2010.03.048

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. https://doi.org/10.1037/0022-3514.90.2.210

Published August 25, 2023

The Current State of Psychedelic-Assisted Therapy: An Overview

Wed, 31 Aug 2022 13:14:22 GMT

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 Medicine, 384(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 Psychiatry, 78, 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 psychiatry, 10, 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. Molecules, 26, 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 medicine, 27, 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. Psychopharmacology, 236, 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 pharmacology, 9, 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 Psychology, 13, 873279.

Published August 31, 2022

An Acceptance-Based Behavioral Therapy for Anxiety and Related Disorders: Mindfulness and Values-Based Action

Wed, 23 Mar 2022 13:20:39 GMT

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 Practice, 23(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.

Hayes-Skelton, S. A., Calloway, A., Roemer, L., & Orsillo, S. M. (2015). Decentering as a potential common mechanism across two therapies for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 83, 395-404.

Hayes-Skelton, S. A., Roemer, L., & Orsillo, S. M. (2013). A randomized clinical trial comparing an acceptance-based behavior therapy to applied relaxation for generalized anxiety disorder. Journal of Consulting and Clinical Psychology, 81(5), 761-773.

Linehan, M. M. (1993). Diagnosis and treatment of mental disorders: Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Martinez, J.H., Suyemoto, K.L., Abdullah, T., Burnett-Ziegler, I., & Roemer, L. (2022). Mindfulness and valued living in the face of racism-related stress. Mindfulness. Advanced online publication. https://doi.org/10.1007/s12671-022-01826-6

Michelson, S. E., Lee, J. K., Orsillo, S. M., & Roemer, L. (2011). The role of values‐consistent behavior in generalized anxiety disorder. Depression and Anxiety, 28(5), 358-366.

Miller, A. & Orsillo, S. M. (2019). Values, acceptance, and belongingess in graduate school: Perspectives from underrepresented minority students. Journal of Contextual Behavioral Science, 15, 197-206.

Millstein, D. J., Orsillo, S. M., Hayes-Skelton, S. A., & Roemer, L. (2015). Interpersonal problems, mindfulness, and therapy outcome in an acceptance-based behavior therapy for generalized anxiety disorder. Cognitive Behaviour Therapy, 44(6), 491-501.

Orsillo, S. M., & Roemer, L.(2016). Worry less, live more: The mindful way through anxiety workbook. New York, NY: Guilford Press

Roemer, L., & Orsillo, S. M. (2002). Expanding our conceptualization of and treatment for generalized anxiety disorder: Integrating mindfulness/acceptance-based approaches with existing cognitive-behavioral models. Clinical Psychology: Science and Practice, 9, 54-68.

Roemer, L.,& Orsillo, S. M. (2020), Acceptance-based behavioral therapy: Treating anxiety and related challenges. New York: Guilford Press.

Roemer, L., Eustis, E. H.& Orsillo, S. M. (2021). An acceptance-based behavioral therapy for generalized anxiety disorder. In D. H. Barlow (Ed). Clinical handbook of psychological disorders: A step-by-step treatment manual (6th ed., pp. 184-216). New York, NY: Guilford Press.

Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083-1089.

Sagon, A. L., Danitz, S. B., Suvak, M. K., & Orsillo, S. M. (2018). The Mindful Way through the Semester: Evaluating the feasibility of delivering an acceptance-based behavioral program online. Journal of Contextual Behavioral Science, 9, 36-44.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2013). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: The Guilford Press.

Serowik, K.L., Roemer, L., Suvak, M. Liverant, G., & Orsillo, S.M. (2019). A randomized controlled trial evaluating Worry Less, Live More: The Mindful Way through Anxiety Workbook. 49, 412-424.

West, L., Graham, J. R. & Roemer, L.(2013). Functioning in the face of racism: Preliminary findings on the buffering role of values clarification in a Black American sample. Journal of Contextual Behavioral Science, 2, 1-8.

Published March 23, 2022

Written Exposure Therapy for Posttraumatic Stress Disorder: An Update

Sat, 26 Feb 2022 14:26:54 GMT

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. https://doi.org/10.1016/j.cbpra.2021.05.004

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. https://doi.org/10.1001/jamapsychiatry.2013.36

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. https://doi.org/10.1093/med-psych/9780190926939.001.0001

Frattaroli, J. (2006). Experimental disclosure and its moderators: a meta-analysis. Psychological Bulletin, 132, 823-865. https://doi.org/10.1037/0033-2909.132.6.823

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. https://doi.org/10.1037/a0030600

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. https://doi.org/10.1037/a0031474

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. _http://doi.org/10.1037/tra0001148

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. https://doi.org/10.1016/j.cct.2021.106564

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. http://doi.org/10.1016/j.beth.2020.03.008

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. https://doi.org/10.1037/ser0000608

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. https://doi.org/10.1016/j.beth.2014.12.002

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. https://doi.org/10.1037/0021-843X.95.3.274

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. https://doi.org/10.1037/0022-006x.72.2.165

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. http://doi.org/10.1037/0000139-001

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. https://doi.org/10.1016/j.brat.2012.07.001

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. https://doi.org/10.1001/jamapsychiatry.2017.4249

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. https://doi.org/10.1001/jamanetworkopen.2021.40911

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. https://doi.org/10.1002/da.22825

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. https://doi.org/10.1002/jts.20146

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. https://doi.org/10.1002/jts.22589

Published February 26, 2022

ACCESS MBCT - Mindfulness-Based Cognitive Therapy (MBCT) Strives for Impact Beyond the Clinic

Fri, 26 Oct 2018 13:29:00 GMT

Zindel Segal, PhD - University of Toronto Scarborough

In 2015 Sona Dimidjian and I published a paper in which we examined the prospects for a clinical science of mindfulness-based interventions (MBIs). We reported that the prospects looked good on the evidence front but were less promising on the public health front. Some might say that mindfulness-based treatments have cleared the hurdle of efficacy only to stumble over the hurdles of reach and impact. Maybe this is a natural developmental trajectory for a set of treatments that have only been around for 20-30 years. One could even argue that it makes sense to demonstrate that a given approach actually works before investing too greatly in its dissemination. But, this argument seems shaky when we consider that Kazdin & Blase made a similar point in 2011 regarding evidence-based interventions, such as BT and CBT, that have been around far longer than MBIs – strong on the data side but weak on delivery side.

I have experienced this phenomenon first hand in my own work with Mindfulness Based Cognitive Therapy (MBCT). With our treatment manual now having been in print for close to 16 years, with a yearly slate of training workshops being offered and with MBCT being listed as a first line prevention intervention in a number of national Depression Treatment guidelines, it is still hard for most people to find an MBCT therapist. This is perplexing. I also know that I am not alone in asking; what good is a well-supported intervention if it sits on the shelf and fails to make it into the hands of those who need it most? My response to this dilemma has been twofold.

One strategy has involved directly focusing on MBCT dissemination and quality by providing the public with a way to find MBCT therapists who have been trained to a recognized level of competence in this approach. Willem Kuyken and I have launched a freely available, searchable, standards-based international registry of MBCT therapists that will allow members of the public to find MBCT therapists who practice in their community. We have named this registry ACCESS MBCT www.accessmbct.com - you can search by either city or country and it will provide you with a list of registered MBCT therapists practicing in your area. Also, if you know the name of a provider and want to see if they are listed on the registry, you can search by name as well.

In this way, ACCESS MBCT serves a quality assurance function. All members of ACCESS MBCT will have to have been trained according to the steps outlined in the MBCT Training Pathway oxfordmindfulness.org/wp-content/uploads/2018/02/MBCT-Training-Pathway.pdf . Adopting this document to set our training threshold reflects the recognition that our field has evolved from the days when having a personal mindfulness practice, a clinical background and familiarity with the contents of Segal et al., 2002 would qualify one to teach MBCT. It is increasingly clear to me that MBCT is not preferentially defined according to its mindfulness or cognitive therapy axes, but rather from the integrative embodiment of these perspectives in the act of teaching. Not surprisingly, additional training experiences are required to develop this capacity and it is our intention that being a member of ACCESS MBCT will communicate this standard to the public. Deciding on this particular framework for ACCESS MBCT was achieved via broad consultation and feedback. We considered a variety of listing/registry models, with varying amounts of oversight and settled on a solution that relies on verifiable self-declarations provided by therapists/applicants interested in joining ACCESS MBCT. Please take a few minutes to check out the ACCESS MBCT website and watch the brief video of the Digital International Announcement for the Registry that was held at the end of 2017 - you may recognize a few familiar faces at www.accessmbct.com.

The second strategy to increase access to MBCT has been to digitize the in-person 8 week program and make it available online so that people could access it from the comfort of their own homes. The program is called Mindful Mood Balance (MMB) and takes a person through 8 separate sessions that present identical content to what folks attending the in-person groups are learning and practicing. While we have some preliminary data indicating that this program is effective in reducing residual depressive symptoms (Dimidjian et al., 2014), we are completing an RCT with 460 patients that will provide a more definitive evaluation. We have also adapted Mindful Mood Balance so that therapists interested in learning MBCT but who can’t find a group in their neighbourhood can complete the program online. MMBPro www.mindfulnoggin.com/mindful-mood-balance is now recognized as an acceptable format for both within the MBCT Training Pathway and is being used to supplement training programs in Canada, the US and the UK.

Needless to say, my graduate training never prepared me to address issues of dissemination and implementation, but it is increasingly clear that for our field to stay relevant in the provision of empirically supported treatments, these are pivotal issues that need to be addressed.

Dimidjian S, Beck A, Felder JN, Boggs JM, Gallop R, Segal ZV. Web-based Mindfulness-based Cognitive Therapy for reducing residual depressive symptoms: An open trial and quasi-experimental comparison to propensity score matched controls. Behav Res Ther. 2014 Dec;63:83-9.

Dimidjian S, Segal ZV. Prospects for a clinical science of mindfulness-based intervention. Am Psychol. 2015 Oct;70(7):593-620.

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Published October 26, 2018

Part II: Cognitive-Behavioral Therapy for the Reduction of Suicide Risk

Mon, 25 Jun 2018 13:42:08 GMT

Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine

Empirical Support for CBT with Suicidal Patients

There is a growing body of research suggesting that CBT-related approaches that specifically target suicidality lead to a reduction in suicidal behavior, at least during the critical period of time following a suicide attempt when the risk for further attempts is high (see Monti, Cedereke, & Ojehagen, 2003) and up to two years of assessed follow-up. Commonalities among the CBT-based treatment approaches reviewed below are more prominent than their relatively minor procedural and terminology differences. What they have in common is an assessment process that uses empathic interviewing, psychometrically supported measures, and a combination of functional analyses and cognitive conceptualizations in order to understand the chain reaction of external events (precipitants and consequences) and internal reactions (thoughts, feelings, physiological responses, and behaviors) that comprise the suicidal crises. Further, these approaches are alike in that they teach suicidal patients psychological skills such as self-monitoring, reflecting on their intended actions rather than responding reflexively, engaging in constructive actions, rationally responding to combat a sense of helplessness and hopelessness, reaching out to their social supports to counteract a sense of isolation, and contacting mental health professionals (including those by whom they are being treated, and others who are “on call,” such as those in hospitals and on crisis hotlines). These interventions can be used as part of a larger, general package of CBT for the full range of problems that patients bring to treatment, or they can be stand-alone treatments. When they are used as single-contact interventions in emergency departments (Stanley & Brown, 2012) or as brief treatments in inpatient facilities (e.g., Ellis & Ruffino, 2015), they can be learned and applied by well-trained mental health professionals regardless of their self-identified theoretical orientation.

A randomized controlled trial showing the efficacy of a brief Beckian cognitive therapy protocol in reducing suicide attempts in a high-risk population was conducted by Brown, Ten Have, Henriques, Xie, Hollander, and Beck (2005). The 120 patients in this study had presented with a suicide attempt in the emergency department, and were recruited within 48 hours for random assignment either to a treatment-as-usual condition or a 10-session cognitive therapy package (identified as Cognitive Therapy for Suicide Prevention, or CT-SP) in addition to treatment as usual (all of which was conducted post-discharge). Participants in the cognitive therapy group were 50% less likely to re-attempt suicide during follow-up, and they showed significantly lower depression and hopelessness. A very similar version of brief CBT was successfully tested in a military sample of active-duty Army soldiers who had made a suicide attempt within the past month or who had suicidal ideation with intent to die in the past week (Rudd et al., 2015). Half of the cohort (n=76) was randomly assigned to the treatment-as-usual condition, and the other half (n=76) was randomly assigned to brief CBT (12 sessions) plus treatment as usual. Similar to the Brown et al. treatment study (2005), the Rudd et al. (2015) program utilized a CBT approach that specifically focused on the symptoms of suicidality (including the patients’ belief systems pertinent to their thoughts about life and death), as well as on safety planning and relapse prevention. During the two-year follow-up period, those receiving CBT were 60% less likely to make a suicide attempt.

The Collaborative Assessment and Management of Suicidality (CAMS: Jobes, 2006; 2012) is a therapeutic approach that self-identifies as being applicable in conjunction with treatments across the theoretical spectrum but nonetheless borrows heavily from CBT methods. In a non-randomized control comparison study, CAMS was associated with reductions in suicidal ideation in comparison to treatment as usual, and was significantly linked to decreases in emergency department utilization during the 6-month follow-up period (Jobes et al., 2005). In a randomized trial, a brief course of outpatient CAMS was shown to reduce suicidal thinking and general symptom distress significantly, and to increase hopefulness and reasons for living at 12-month follow-up more so than an enhanced care-as-usual approach (Comtois et al., 2011). When provided to hospitalized patients in an individual therapy format, CAMS led to significantly greater improvements on measures specific to suicidal ideation and suicidal cognitions compared to inpatients who did not receive the CAMS interventions (Ellis, Rufino, Allen, Fowler, & Jobes, 2015).

Safety Planning Intervention (SPI: Stanley & Brown, 2012) consists of the same steps as described earlier, but in a condensed, written format that serves as a guide to aftercare and follow-up when suicidal patients exit the emergency department following a single contact. The basic elements of the written SPI are: (1) identifying early warning signs of heightened suicide risk, (2) employing prepared, internal coping strategies, (3) utilizing social settings and contacts to distract from suicidal preoccupation, (4) contacting friends and family members for support in times of crisis; (5) contacting mental health practitioners or agencies, and (6) restricting access to lethal means. Stanley and Brown (2012) report that SPI has been used as part of other evidence-based psychotherapy interventions in clinical trial research.

Another CBT approach that has been applied to suicidal individuals in inpatient settings is Post Admission Cognitive Therapy (PACT: Ghahramanlou-Holloway, Cox, & Greene, 2012). PACT emphasizes helping patients face the stressors that are often encountered following discharge from hospital; stressors that if not managed properly can easily trigger a relapse of suicidal thoughts, feelings, urges and behaviors. Indeed, the period of time when patients are re-acclimating to life outside of the hospital is a period of high risk for another suicide attempt (Ghahramanlou-Holloway, Neely, & Tucker, 2015). PACT has the same treatment objectives as outpatient CBT (e.g., identifying and modifying the cognitive, emotional, and behavioral factors that comprise the patient’s “suicidal mode”), but also helps patients develop the problem-solving skills they will need on the outside. The goals include improving the patient’s self-efficacy in dealing with the demands of their life situation and increasing their compliance with adjunctive medical, social, psychiatric, and substance abuse interventions both during and after hospitalization. In a highly related line of clinical research, a subset of problem-solving that focuses on emotional self-regulation and interpersonal concerns (Emotion-Centered Problem-Solving Therapy: EC-PST, Nezu & Nezu, in press) is also showing promise as a means by which to help highly distressed persons to feel more personally empowered, and to refrain from translating negative affect into self-harm.

It is also important to acknowledge the contribution of dialectical behavior therapy (DBT) to the treatment literature on suicide risk reduction (e.g., Linehan et al., 2006; Linehan et al., 2015). Although DBT is a distinct treatment that involves components of care that are not routinely included in standard CBT packages (e.g., a DBT skills group to go along with individual treatment; regular between-sessions phone contacts), DBT and the CBT approaches mentioned in this review have the same common theoretical roots. Brown et al. (2012) note that their CT-SP treatment and DBT both focus on preventing suicidal behavior by teaching high-risk patients specific coping skills. A noteworthy component of DBT is mindfulness, a self-regulation skill that itself has some empirical support as a method that reduces suicidal behavior in those at risk (see Chesin, Sonmez, Benjamin-Beeler, Brodsky, & Stanley, 2015).

CBT can be applied to suicidal children and adolescents. For example, a randomized controlled trial conducted by Esposito-Smythers and Spirito (2004) on hospitalized adolescents with a substance use disorder and at least one suicide attempt in the previous three weeks showed the superiority of CBT over enhanced treatment as usual on outcomes related to substance use, suicide attempts, emergency department visits, and arrests. The adolescents who received CBT also showed better treatment adherence. Another CBT approach currently being applied to the treatment of suicidal adolescents is the aptly named Treatment of Adolescent Suicide Attempters (TASA: Brent et al., 2009). The authors emphasize the importance of safety planning and increased frequency of therapeutic contact early in treatment. Additionally, a treatment model for young suicidal patients that includes working with the family -- called Safe Alternatives for Teens and Youths (SAFETY) – was shown in a randomized, controlled trial to reduce suicide attempts in adolescents presenting with recent self-harm (Asarnow, Hughes, Babeva, & Sugar, 2017). The authors describe the SAFETY program as a cognitive-behavioral, dialectical behavior-therapy informed family treatment.

Although the studies noted above suggest that even brief CBT interventions for suicidality can be efficacious, a longitudinal approach to the treatment of suicidality may be best. There is evidence that even when patients respond well to treatment they are prone to residual symptoms – including sub-optimally modified dysfunctional beliefs about suicide – that may keep them at elevated risk in the future. Also, in outpatient work with suicidal individuals, spotty attendance and early drop-out from treatment take on added significance. There is evidence that those patients who are most at risk (e.g., having a history of multiple suicide attempts) tend to be least likely to avail themselves of regular therapy sessions (see Berk, Henriques, Warman, Brown, & Beck, 2004; Joiner & Rudd, 2000). Similarly, suicidal patients who opt to discontinue therapy without having a formal concluding session to summarize their gains and formulate a maintenance plan, and/or while still demonstrating hopelessness (e.g., as assessed via their last-completed BHS) are at higher ongoing risk for suicide than those who complete treatment with a better sense of hope and direction (Dahlsgaard, Beck, & Brown, 1998). Thus, therapists cannot remain passive when their suicidal patients are absent from treatment in an unanticipated way. Instead, therapists would do well to try to reconnect with the patients, such as by calling and leaving caring messages that invite the patients to come in for an appointment as soon as possible (Brown et al., 2012). A randomized controlled trial by Motto and Bostrom (2001) also showed that even after therapy is completed, some simple acts of positive outreach (e.g., a birthday card with a pleasant message) can lower suicide risk well after termination.

Concluding Comments

Helping a patient to relinquish suicidal intentions and behaviors is a process. The CBT practitioner makes gradual inroads by establishing a genuinely caring therapeutic relationship, constructing a clear and comprehensive framework for the work of therapy, collaborating with the patient on a treatment plan involving skill-building and safeguarding, and offering a steady flow of words of empathy, support, encouragement, and hope. No single intervention in any given session is likely to put a definitive end to the patient’s risk for suicide. However, each intervention contributes to an incremental lowering of risk, especially if the therapist succeeds in motivating the patient to practice a range of self-help methods between therapy sessions for homework. In sum, the therapist offers the suicidal patient hope and a plan, bolstered by a healthy therapeutic relationship characterized by accurate empathy for the patient’s unique experiences, and ongoing positive reinforcement for learning durable psychological skills.

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Bryan, C. J., Rudd, M. D., Wertenberger, E., Etienne, N., Ray-Sannerud, B. N., Peterson, A. L., & Young-McCaughom, S. (2014). Improving the detection and prediction of suicidal behavior among military personnel by measuring suicidal beliefs: An evaluation of the Suicide Cognitions Scale. Journal of Affective Disorders, 159, 15-22.

Chesin, M. S., Sonmez, C. C., Benjamin-Phillips, C. A., Beller, B., Brodsy, B. S, & Stanley, B. (2015). Preliminary effectiveness of adjunct mimdfulness-based cognitive therapy to prevent suicidal behavior in outpatients who are at elevated suicide risk. Mindfulness, 6, 1345-1355.

Clemans, T. A. (2015). A cognitive behavioral model of suicide risk. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 51-64). New York: Routledge.

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Dahlsgaard, K. K., Beck, A. T., & Brown, G. K. (1998). Inadequate response to therapy as a predictor of suicide. Suicide and Life-Threatening Behavior, 28, 197-204.

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Ellis, T. E., & Rufino, K. A. (2015). A psychometric study of the Suicide Cognitions Scale with psychiatric inpatients. Psychological Assessment, 27, 82-89.

Ellis, T. E., Rufino, K. A., Allen, J. G., Fowler, J. C., & Jobes, D. A. (2015). Impact of a suicide-specific intervention within inpatient psychiatric care: The Collaborative Assessment and Management of Suicidality (CAMS). Suicide and Life-Threatening Behavior, 45, 556-566.

Esposito-Smythers, C., & Spirito, A. (2004). Adolescent substance use and suicidal behavior: A review with implications for treatment research. Alcoholism: Clinical and Experimental Research, 28, 77S-88S.

Flett, G. L., Hewitt, P. L., & Heisel, M. J. (2014). The destructiveness of perfectionism revisited: Implications for the assessment of suicide risk and the prevention of suicide. Review of General Psychology, 18, 156-172.

Ghahramanlou-Holloway, M., Cox, D., & Greene, F. (2012). Post-admission cognitive therapy: A brief intervention for psychiatric inpatients admitted after a suicide attempt. Cognitive and Behavioral Practice, 19, 116-125.

Ghahramanlou-Holloway, M., Neely, L. L., & Tucker, J. (2015). Treating risk for self-directed violence in inpatient settings. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 91-109). New York: Routledge.

Green, K. L., & Brown, G. K. (2015). Cognitive therapy for suicide prevention: An illustrated case example. In C. J. Bryan (Ed.), Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 65-88). New York: Routledge.

Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach. New York: Guilford.

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Published June 25, 2018

Part I: Cognitive-Behavioral Therapy for the Reduction of Suicide Risk

Mon, 25 Jun 2018 13:31:51 GMT

Cory Newman, PhD - Center for Cognitive Therapy, University of Pennsylvania Perelman School of Medicine

Introduction

Suicide is a significant public health problem both at home and abroad, and therefore is an area of major importance for mental health intervention. Cognitive-behavioral interventions that specifically target suicidality are showing promise in significantly reducing potentially lethal self-directed violence in patients at high risk.

Assessment

When patients present with suicidal ideation, intent, and/or recent self-harming behaviors, the clinician conducts a comprehensive suicide risk assessment (Bryan, 2015; Wenzel, Brown, & Beck, 2009). An assessment includes interviewing patients about their suicidal thoughts, observing their behavior directly, obtaining information from other pertinent sources (e.g., medical records, verbal reports from others, family history), and using psychometrically sound assessment inventories (several of which appear in Box 1).

Box 1. Inventories to Assess Suicidality
The Beck Scale for Suicide Ideation (BSSI: Beck, Kovacs, & Weissman, 1979): The BSSI is an interview-based instrument that addresses multiple factors pertinent to a patient’s suicidality. The BSSI includes a section that inquires about the patient’s worst past episode of suicidality. This adds important information, as there is evidence that future risk for suicide is significantly linked to past severity of suicidality, even if the patient’s current risk level is low (Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999; Joiner, Steer, Brown, Beck, Petit, & Rudd 2003).
The Beck Hopelessness Scale (BHS: Beck, Weissman, Lester, & Trexler, 1974): The BHS is a 20-item “true-false” self-report inventory that assesses patients’ views of their future, with such items as, “I might as well give up because there is nothing I can do about making things better for myself.” Hopelessness has been shown to be a mediator between depression and suicidality, and has predictive validity for deaths by suicide (Brown, Jeglic, Henriques, & Beck, 2006).
The Beck Depression Inventory-II (BDI-II: Beck, Steer, & Brown, 1996): This 21-item self-report measure of the severity of depression contains items pertinent to hopelessness (#2) and suicidality (#9). When patients fill out the BDI-II at each session, therapists can eyeball these two scoring items for a quick, concise understanding of the patients’ current level of suicide risk, and can ask the patients to discuss their inventory responses as part of the session agenda.
The Columbia-Suicide Severity Rating Scale (C-SSRS: Posner et al., 2011): The C-SSRS is an interview-based scale measuring patients’ past and current suicidal ideation and behavior. It addresses the four constructs of severity, intensity, behavior, and lethality.

The Suicide Cognitions Scale (SCS: Bryan et al., 2014): The SCS is an 18-item self-report instrument. Patients rate their strength of belief in each item on a 0-5 Likert-type scale. The two main constructs underlying the items are the suicidal schemas of unbearability and unlovability.

If a patient presenting for treatment has previously engaged in self-directed violence, the clinician inquires about the patient’s level of intent (e.g., impulsive versus planned; communicating the need for help versus wanting to die), degree of lethality of the method used (e.g., taking several pills or superficially cutting one’s wrist, versus trying to hang oneself), presence and extent of actual physical injury, whether or not the suicide attempt was interrupted (and by whom), and situational context and triggers. It is also important to determine if the current suicide attempt was the first time or the latest in a historical pattern, as patients who have a history of multiple suicide attempts are particularly at risk (Joiner & Rudd, 2000).

It is also advisable to construct a chain analysis that includes the sequence of events precipitating the suicide attempt, the patient’s resultant thoughts, emotions, and behaviors, as well as the consequences (Brown, Wright, Thase, & Beck, 2012). This process assists in providing patients with valuable psycho-education about their vulnerabilities and related targets for intervention. In terms of ongoing treatment, therapists can explain to their patients that they will ask about their suicidal ideation, intentions, and behaviors as a routine part of each session, because they will need to be vigilant for emergent recurrences of increased risk.

Unlike the more traditional syndromal model that viewed patients’ suicidality as secondary to their psychiatric diagnoses, current cognitive-behavioral approaches directly assess and target the suicidality as a primary issue. Therapists examine the antecedent and consequent contextual influences as well as the patient’s belief systems that interact to initiate and maintain suicidal feelings and behaviors (Clemans, 2015). For example, the therapist may hypothesize that a patient receives negative reinforcement for cutting herself in that she provides herself with a temporary distraction from her emotional pain that she considers much worse. She may also receive some positive reinforcement for her self-harming behaviors when people close to her increase their demonstrations of care and concern. In another case, the therapist posits that the patient’s suicidal ideation and intent are congruent with his stated self-punitive belief “I am a bad person who doesn’t deserve to live.” When other people (including the therapist) give this patient support and positive feedback, he has great difficulty believing it, thus he appears to be unresponsive to help. Exploring such factors contributes greatly to the formulation of a cognitive-behavioral case conceptualization (see Kuyken, Padesky, & Dudley, 2009) that can increase the practitioner’s accurate empathy, and guide the construction of a treatment plan for the suicidal patient.

Cognitive Vulnerabilities Associated with Suicidality

A CBT approach to the assessment and treatment of suicidality pays close attention to the cognitive characteristics associated with suicide risk. For example, hopelessness has been found to be a significant factor in differentiating non-suicidal persons from those who are potentially at elevated risk for suicide (Beck, Brown, Berchick, Stewart, & Steer, 1990; Beck, Steer, Beck, & Newman, 1993; Beck, Steer, Kovacs, & Garrison, 1985; Brown, Beck, Steer, & Grisham, 2000; Brown, Jeglic, Henriques, & Beck, 2006; Smith, Alloy, & Abramson, 2006).

In addition to general hopelessness, there are specific beliefs that have been found to be related to suicide risk. For example, suicidal patients have a tendency to believe that they are unlovable, that their problems are unsolvable, that their pain is unbearable, and/or that they are a burden to others (Ellis & Rufino, 2015; Joiner et al., 2009; Peak et al., 2015).

Cognitive rigidity or inflexibility has also been identified as a characteristic in suicidal thinking (Miranda, Gallagher, Bauchner, Vaysman, & Marroquín, 2012; Miranda, Valderrama, Tsypes, Gadol, & Gallagher, 2013). Suicidal persons are prone to evaluating themselves and their lives in all-or-none terms. For example, situational self-reproach becomes blanket self-condemnation, and/or an adverse event seems inexorable and devastating.

Perfectionism is also a cognitive risk factor for suicide (Flett, Hewitt, & Heisel, 2014; O’Connor, 2007). “Morbid” perfectionism goes way beyond just a stubborn desire to get things right. It entails a patient’s internal demand to have things be “just so,” and to be punitive toward oneself, excessively concerned about others’ negative judgments, and angry at the world if things turn out differently. Within this mindset, the minor setbacks of everyday life become triggers for emotional crises, and larger disappointments become reasons to want to die (e.g., “If I don’t pass the Bar Exam this time, I will kill myself”).

Interventions

It should be noted that the term “interventions” does not just mean “techniques,” as interventions are intertwined with and highly dependent upon the quality of the therapeutic relationship and case conceptualization (see Newman, 2015). Similarly, the term “interventions” goes beyond what transpires in the therapist’s office. It also refers to the patient’s homework assignments, in which they practice in everyday life what they learned in their CBT sessions. Homework assignments can also include self-help readings that supplement and are congruent with the treatment (e.g., Choosing to Live: How to Defeat Suicide Through Cognitive Therapy, Ellis & Newman, 1996). Several major areas of intervention are described below.

Safety Planning – “Safety planning” refers to formal methods for keeping suicidal patients safe between therapy sessions (Stanley & Brown, 2012; Wenzel et al., 2009). Safety planning entails the implementation of good, standard risk management methods, including identifying, promoting, and utilizing the patients’ interpersonal and intrapersonal resources. The typical components of outpatient risk management include increasing the frequency of sessions, scheduling between-session phone contacts, making arrangements for the patient to spend time in public places around other people (e.g., cafés, bookstores, parks, sporting or community events, malls) and/or with selected others who can provide some measure of oversight (e.g., friends, family, support group cohorts), and doing advance problem-solving to reduce the likelihood of the patient’s being in situations that might increase risk. The risk management methods above involve a strong interpersonal component, in which the patient is prepared to reach out to (and spend time with) others. Patients should have ready access to important contact information, including phone numbers for their practitioners and suicide hot lines. The interpersonal part of the safety plan can also be utilized to enact a lethal means restriction – that is to say that important people in the patient’s life are enlisted to help remove whatever poses a potential danger to the patient. For example, a trusted family member can take possession of the patient’s firearm(s) for safe storage (see Simon, 2007), or a person in the patient’s household can take charge of doling out the patient’s medications in small increments to lower the risk of deliberate overdose. When patients do not wish to give up their instruments of self-harm (e.g., firearms, razors, pills), the risk of a power struggle can be lowered by adopting a therapeutic negotiating style known as motivational interviewing (Miller & Rollnick, 2002), which can be utilized to take steps toward reducing access to lethal means (Britton, Bryan, & Valenstein, 2016).

The intrapersonal piece in safety planning has to do with the patient learning to spot early warning signs of increasing suicidality and being ready and agreeable to use the full array of self-help coping skills he or she is learning in CBT. The key self-help skills, which can be used at times of acute need as well as throughout a course of treatment and beyond, are described below.

Building Psychological Self-Help Skills – In order to help patients make therapeutic gains that will be well-maintained for the long term, CBT helps patients develop and practice durable psychological skills. Some of these interventions include, (1) developing hopefulness and reasons for living, (2) rationally responding to suicidogenic beliefs, (3) constructing a compassionate narrative of one’s own life, (4) creating a “hope kit,” (5) improving problem-solving, (6) engaging in activities that bring a sense of accomplishment and enjoyment, and (7) preparing for potential high-risk situations to prevent relapse (see Ellis & Newman, 1996; Wenzel et al., 2009).

Developing Hopefulness and Reasons for Living – CBT therapists validate their patients’ experiences of subjective emotional pain, but also invite them to consider ways in which this pain may be eased within the scope of an improved life and a more hopeful future. A simple, straightforward technique that can be very enlightening is discussing and writing the pros and cons of dying by suicide versus investing in living (Ellis & Newman, 1996; Jobes, 2006; Brown et al., 2012). This method gives patients overt permission to identify the “advantages” of suicide that they have already been dwelling upon, and to talk about the topic openly with the therapist (see Figure 1). Often there are obvious cognitive biases that are identified in the course of fleshing out the “pros of dying” (e.g., “My family will be better off if I kill myself”), and these beliefs can be subjected to rational responding (see below). Meanwhile, the therapist engages the patient in a process of considering the advantages of investing in life going forward, something that the patient may have been discounting or neglecting. A further application of this technique involves discussing the pros and cons of the patient’s living versus dying for the patient’s loved ones. Doing so often motivates patients to think about the well-being of their family and other important people in their lives as a deterrent to suicide.

Figure 1. Advantages/Disadvantages Analysis

Rationally Responding to Suicidogenic Beliefs – Suicidal patients are taught to identify their beliefs that potentially support their suicidal feelings and intentions, and to use cognitive restructuring techniques (see Newman, 2015) in an attempt to modify these dangerous beliefs. Many suicidal patients evince rigid, maladaptive beliefs that are not easy to relinquish. However, therapists try to create “reasonable doubt” in the minds of such patients about their notions (for example) that death is the only “solution” to their problems, or that they are so bad that they “deserve” to die. Rational responding is not the same thing as “thought replacement.” The more apt description is that rational responding plants seeds of hope that can sprout over time with the help of a strong therapeutic relationship. Patients are taught that it is not necessary for them to fully believe their own rational responses – it is progress in itself if they can simply generate more hopeful, more constructive beliefs that can be tested, or if they are willing to partially believe their therapist’s attempts at hopeful reframing. Even tentatively believed rational responses can gain greater acceptance over time, as other interventions take hold.

Constructing a Compassionate Narrative of One’s Own Life – In order to gain a broader perspective on their lives, to escape the “time trap” of being unduly focused on the pain of the moment, to improve specific autobiographical recall, and to imagine a better future, suicidal patients are encouraged to write a compassionate narrative of their lives. It is best if this technique is done in stages, across sessions, so that it can grow into a detailed, thorough story, and so that it can become a useful, ongoing homework assignment. An additional narrative can be added that describes positive possibilities for the future. For example, the patients can be asked to list three positive and/or interesting things they might experience each year going forward – things that they would miss if they were to die by suicide (see Ellis & Newman, 1996).

Creating a “Hope Kit” – A hope kit (see Wenzel et al., 2009) is a compilation of positive memorabilia that patients can store in a shoebox, a phone app, or a computer file. Once patients do the work of putting a hope kit together (an excellent homework assignment), they can continue to add to it as new events come up that serve as reminders about what is valuable in their lives. The contents of hope kits typically include such items as photos of happier times and events, birthday and greeting cards that the patient has received over the years, personal archives that represent success experiences (e.g., awards, certificates, congratulatory notes), and mementos from favored activities (e.g., trips, clubs, organizations). Additionally, patients can add emotionally significant and meaningful things they have produced, such as artwork, crafts, and writings, including the best examples of previous therapy homework assignments. Consistent with the information used in a safety plan, the hope kit can also include a list of important people in the patient’s life along with their contact information. The main purpose of the hope kit is to produce evidence that suicidal patients do indeed have important attachments to life, and to remind them why their existence is worth preserving and nurturing.

Improving Problem-Solving – Suicidal patients sometimes feel overwhelmed by life’s problems (and/or by their perceptions of life’s problems) and see no way out other than escaping from life itself. This is where therapists need to teach their patients basic problem-solving skills, including describing problems objectively, brainstorming solutions, weighing pros and cons, implementing chosen methods, evaluating the outcomes, and beginning the process with another problem (Nezu, Nezu, & D’Zurilla,2013). Even when patients have bona fide crises and hardships, therapists offer empathy along with a lesson in the benefits of doing “damage control” to begin to turn things around for the better. There is evidence that the subset of problem-solving known as social problem-solving (also called emotion-centered problem solving, see Nezu & Nezu, in press) – which pertains to interpersonal and emotional self-regulation skills – is particularly germane to suicidality in that deficiencies in this area are a risk factor (Nezu, Nezu, Stern, Greenfield, Diaz, & Hayes, 2017; Woods, 2018). Such findings suggest that treatment should teach patients to view their negative emotions and interpersonal concerns as problems that can be addressed constructively and with self-efficacy, rather than as indicators of uncontrollable, intolerable misery.

Engaging in Activities for Accomplishment and Enjoyment – Therapists help their patients brainstorm a list of activities in which to engage, particularly those that have the potential to be enjoyable and/or to provide a sense of accomplishment. Sometimes an excellent source of ideas for this list comes from a review of the things that the patient used to do and/or has been meaning to do. Deeply depressed patients are prone to minimizing the meaning or importance of such activities, and often assume that taking part in the activities will fail to make them feel better anyway. Practitioners of CBT encourage patients to increase their level of activity step by step as a therapeutic experiment to test hypotheses about the potential impact. When patients begin to do positive, constructive things, it often improves their morale, provides some hope, and helps in the process of connecting with others and/or solving problems. All of this serves as a counterweight to suicidality.

Preparing for Potential High-Risk Situations to Prevent Relapse – The skills described above require regular practice to minimize the risk of relapsing into suicidal crises. This involves such methods as reviewing and documenting the patient’s self-help strategies (e.g., drawing from earlier homework assignments), updating the safety plan to incorporate new material (e.g., new activities, additional people to contact), and organizing and assembling “coping cards” that contain the best of the patient’s rational responses to the re-emergence of old stress reactions. Coping cards can be index cards, or memos on the patient’s phone or other digital device. A particularly powerful relapse prevention method is the guided imagery exercise described by Green and Brown (2015), in which the therapist instructs the patient to imagine anticipated situations in the future that could have the potential to trigger suicidal ideation and intentions. Patients then have to provide a detailed account of the coping methods they would use in such situations. This method serves as an important measure of the patient’s preparedness for the maintenance and ending phases of a treatment trial.

Published June 25, 2018

Three Levels of Family Involvement in the Treatment of Childhood Anxiety: Education, Coaching and Improving Family Relationships

Sat, 03 Feb 2018 14:43:42 GMT

Lynne Siqueland, PhD - Children's and Adult Center for OCD and Anxiety

It is useful to consider three levels of family involvement when conceptualizing and planning treatment of child and adolescent anxiety: education, coaching parents and other family members and caregivers, and improving family relationships. This conceptualization has been useful for assessment of needs and clinical decision making by articulating levels of intervention for the treatment of childhood anxiety and related disorders. These three levels of intervention have also been suggested by other clinical investigators who have written about family factors relevant in child anxiety (Rapee, 2012). In what follows, straight forward language is offered that can be used by clinicians and other providers when speaking directly to parents and children in practice.

Psychoeducation about anxiety

Cognitive-behavioral therapists overall rely on psychoeducation as an essential part of their work. The first level of intervention then is psychoeducation about the nature of anxiety in children and an understanding of what ameliorates or exacerbates anxiety. This is the starting point and often essential for all families. It is useful to teach parents about what anxiety looks like in children and teens in terms of body reactions, thoughts and behavior. Many children and parents are not aware of the links between physical symptoms and anxiety. It helps for them to notice patterns. If, for example, a child is complaining of stomach pain each school day morning but does not have difficulty or pain during the school day or after school in the afternoons or weekends then there is likely a link to anxiety or separation fears rather than stomach condition alone.

Also clarifying for parents that the discomfort or pain is real but will often be relieved by managing anxiety rather than treating the stomach or other regions of the gastrointestinal system with medications can be helpful. Or addressing anxiety first can help clarify physical symptoms that remain after anxiety is lessened. Headaches and stomachaches are the most common physical symptoms reported along with vague physical complaints. Finally sleep issues are common in anxiety, especially around falling asleep. If sleep issues are caused primarily by anxiety then treating worry or separation anxiety in the daylight hours is often essential before there can be success in sleep difficulties. Another important psychoeducation issue is the reverse. Too little or disrupted sleep can cause anxiety and treating sleep issues may significantly reduce anxiety without formal treatment of the anxiety. Indeed psychoeducation and information alone has been helpful in child anxiety (Ginsburg, Drake, Tien et al., 2015). For some children and families education may be all they need to address concerns.

Cognitive-behavioral therapy (CBT) can be especially helpful in teaching youth and parents to recognize that there are thinking patterns that arise when anxiety is present, including beliefs that anxiety is problematic or dangerous. The first reaction the child shows is the anxiety reaction – it is automatic and often inaccurate or “false alarm”. For children and teens, that anxiety reaction is either a “freak-out” as kids often call it, or a “No” or refusal to do something or a combination of both. It helps parents and other caregivers to recognize this first response as the anxiety reaction and not how their child thinks or feels when not anxious. While it is clear that the child may not be able to help the first reaction, the child is expected to learn, and the parents are to help their child cultivate, another more reasonable response. It helps everyone to not be surprised or disappointed or to panic if the anxiety reaction occurs. Instead they can respond by calmly saying, “We thought this might happen and we have a plan.”

Finally the major issue for parents to understand is how avoidance maintains anxiety. Many parents understand this at higher levels of avoidance but not in the subtler versions of day-to-day living. It really helps for parents to understand that it is true that the anxiety goes down in the short run if they take over for a child (contact a friend or teachers for them) or allow a child to not attend a planned activity or event. However, avoidance maintains and exacerbates the anxiety in the long-run. Both prevention and intervention trials have targeted working with parents alone and providing educational information with good outcomes (e.g. Ginsburg, Drake, Tein, et al., 2015); Thirlwall, Cooper, Karalus,, Voysey, Willetts & Creswell, 2013).

Coaching Caregivers to Coach Children

The second component of coaching children during anxious moments comes into the clinical plan and is usually needed to some extent for all child and teen clients and their parents. If parents have a way to help their children rather than the past options of trying to force their child, getting angry, or letting their child avoid, then parents feel that they can do something. Also kids feel empowered because they also have something useful and different to do in the moment so often they are more willing to approach situations. The therapist reminds parents and child clients that humans forget or do not use their therapeutic strategies at first and especially in times of stress if the strategies have not been sufficiently practiced. It takes repeated practice for new skills to become available in times of stress. So it is important to review tools non-reactively and before they are needed, including after stressful events in anticipation of the next time. Overall, therapists want both kids and parents to know that anxiety disorders are no-fault conditions. Everyone is doing the best they can but in treatment parents and kids are asked to do some things differently based on what mental health professionals know about the nature of anxiety.

It is important to educate children, teens and their parents about the nature of exposures to feared situations and symptoms. There is no force involved but instead the therapist, child and parent are work together to make a plan to face fears step by step. Children and teens should be told ahead of time what is going to happen, and informed that parents are going to do things differently. Everyone in the family is told that it can be hard at first and uncomfortable but gets better with practice and time. One essential fact to learn about anxiety is that it often goes away on its own with doing next to nothing. The reaction to the anxiety is the problem more than the anxiety itself. Parents and kids see that you often do not have to use all cognitive or behavioral approaches for anxiety to change if you just expose yourself to the feared situation and pay attention to the actual objective outcome. The anxiety goes up and down on its own. One of the pieces of coaching advice is that “this bad feeling will pass.” Anxiety does not mean you have to do something. This fact alleviates pressure on children, teens and their families alike.

Parents and their children have a role in CBT treatment. Parents’ role in exposures is making time for exposures at home, taking kids places to do them and setting up plans like playdates. In this new role, parents are limiting reassurance, working to stay calm, and encouraging a different way of asking for help. Most importantly, therapists help parents pay a lot of attention to kids’ healthy coping responses and a lot less to anxiety. They can help their children use the CBT strategies or just simply help their children continue or return to what they would be doing if anxiety were not getting in the way. Psychologist Deborah Ledley, Ph.D. describes the child’s primary instruction as “just do it”- try the exposures planned, use your strategies and do not get too mad at your parents for taking you to treatment or asking you to do homework.

Many parents, with the psychoeducation and coaching, can do a great job and rather quickly take over the role as an encouraging side-by-side coach or background coach for their children. However some parents and families have difficulty doing this. If one or both parents have significant anxiety, and especially if the anxiety is untreated, they may be modeling an anxious response in words or other behaviors or may not be able to complete exposures. Many parents with anxiety who have formally received treatment or found their own ways to challenge themselves despite anxiety can be excellent coaches.

Parents very appropriately model for their kids coping by speaking out loud in the moment how they cope or describe how they coped in past situations. A parent might say, “I was pretty nervous to talk to someone at work about something I did not like because I did not want them to be mad at me or I did not want to look stupid. So I thought about how I wanted to say it and looked for a good time to talk to my coworker. It was hard because they were a little upset when I talked to them, but later at lunch we were able to talk again comfortably.” Often parents who cannot manage their own anxiety particularly well can still provide support and coaching for their child.

Other parents with or without anxiety might have strongly held beliefs either about parenting or anxiety that make it hard for them to feel that it is ok or safe for their child to be anxious. Oftentimes a session or two with parents alone focused on hearing their concerns with patience and understanding can lead these to be evaluated and challenged by attending to their child’s actual experience in treatment. It can be really enlightening for a parent to see a child either do an exposure with the therapist or come back from an exposure and report to the parent what they did. For example, parents will be surprised sometimes to hear the child did an exposure such as asking for a book in a bookstore or talking to another child in the waiting room. Seeing their child actually competent in doing these tasks helps challenge the belief about the child or anxiety. Also if there is one parent who is less anxious, that parent can do the exposures alone with the child first to help the child feel confident and competent and then transition to practicing with the more anxious parent.

Family accommodation has been well documented to directly relate to severity of OCD and anxiety symptoms. Improvements in limiting family accommodation lead to improvements in OCD and anxiety symptoms. Whereas in OCD family accommodation is often related to involvement in rituals, in the other anxiety disorders accommodation can take forms such as allowing avoidance or doing things for the child rather than promoting independence (Liebowitz, Scharfstein & Jones,2014; Merlo, Lehmkuhl, Geffken & Storch, 2009).

Improving Relationships with Caregivers

The third level of intervention is work on improving family relationships including improving communication, lowering conflict and promoting autonomy and independence. In some families, the level of conflict or anger or difficulties in communication can really limit the ability to do the CBT treatment. Therapists can decide if they have the interest in and experience working with families on these issues prior to or concurrent with CBT treatment. Otherwise families can be referred to individual, couples or family treatment with another provider. Both research studies and clinical experience show that many children and teens can make major improvements in CBT treatment even if their family does not change so it is important to keep offering the individual treatment option even in the family is not willing to engage in family work. The main difficulties that can arise when just an individual treatment model is used include therapy-interfering behaviors that take the form of parent accommodation, avoidance or parental difficulty helping children in anxious moments.

However other therapists can decide to take on the often rewarding and crucial work in some cases to meet with different family members to improve communication, lower conflict, increase closeness and attachment. Especially teens, but also younger children, are amazing at telling their parents how they feel when their parent reacts in a certain way. They might be able to tell parents how they feel when their parent gets anxious, or how it feels when the parent is mad when the child cannot help their anxiety reaction. For some families individuation and contrasting beliefs or choices are compromised for fear of conflict, hurting others feelings, or guilt. This family work is best done carefully and thoughtfully and working with child, parents / caregivers or dyads separately to plan for different kinds of conversations. Therapists can evaluate for kids and teens whether it is safe or useful for a child or teen to express their feelings and whether or not the parent is willing to listen and can be helped to hear. Families can be helped to promote competence and independence in their children and to “enact” different conversations and interactions (Bogels & Siqueland, 2016). Parents also need a safe place to discuss any differences in parenting philosophy or beliefs about anxiety that are limiting their ability to help their child. Therapists can often help parents to find a compromise approach or to respectfully tag team using different strengths and contributions of each parent. This third level of intervention is not needed for all families.

Bogels, S & Siqueland, L. (2006). Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45(2) 134-141.

Ginsburg, GS, Drake KL, Tein JY Teetsle, R and Riddle, M. (2015). Preventing Onset of Anxiety Disorders in Offspring of Anxious Parents: A Randomized Controlled Trial of a Family-Based Intervention. American Journal of Psychiatry, 172:1207-1213.

Lebowitz ER, Scharfstein LA and Jones. J. (2014). Comparing family accommodation in pediatric obsessive-compulsive disorder, anxiety disorders, and nonanxious children, Depression and Anxiety, 31(12):1018-25.

Manassis K., Lee, T.C., Bennett, K., et al (2014). Types of parental involvement in CBT with anxious youth: a preliminary meta-analysis. Journal of Consulting and Clinical Psychology, 82 (6):1163–1172.

Merlo, L, Lehmkuhl, HD, Geffken, GR & Storch, E A (2009). Decreased family accommodation associated with improved therapy outcome in pediatric obsessive–compulsive disorder, Journal of Consulting and Clinical Psychology, Vol 77(2), 355-360.

Rapee, RM (2012). Family Factors in the Development and Management of Anxiety Disorders, Clinical Child and Family Psychology Review, Volume 15 (1) pp 69-80

Thirlwall, K, Cooper, PJ, Karalus, J, Voysey, M, Willetts L, Creswell C (2013). Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial. British Journal of Psychiatry. Dec; 203(6): 436-44.

Note: This article is based on the PBTA workshop entitled, “Family involvement in the treatment of children with anxiety disorders,” that was given by Lynne Siqueland, Ph.D. and Deborah Ledley, Ph.D. http://philabta.org/event-1878131

Published February 3, 2018

Improving the Implementation of Exposure Therapy

Sat, 02 Sep 2017 13:45:29 GMT

Joanna Kaye, MS - Department of Psychology, Drexel University

A large body of literature has determined that exposure-based cognitive-behavioral therapies are highly effective for a variety of anxiety disorders (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012; Newby, McKinnon, Kuyken, Gilbody, & Dalgleish, 2015). Exposure therapies (ET) refer to a group of treatments that use exposure techniques to help individuals confront feared stimuli in a prolonged, repeated, and intense manner (Richard & Lauterbach, 2007). The various forms of exposure techniques include in vivo exposure (i.e., directly confronting feared stimuli in the real world), simulated exposure (i.e., confronting feared stimuli through role-play or “simulated” real-world scenarios), imaginal exposure (i.e., recounting anxiety-provoking thoughts or images verbally or in the form of written narratives), and interoceptive exposure (i.e., intentionally invoking feared body sensations).

Meta-analyses have determined that exposure-based cognitive-behavioral treatments (CBTs) lead to symptom improvement with large effect sizes in the treatment of panic disorder, specific phobia, social anxiety disorder (SAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD; Bandelow et al., 2015; Deacon & Abramowitz, 2004; Mayo-Wilson et al., 2014; Olatunji, Davis, Powers, & Smits, 2013; Olatunji et al., 2010). Additionally, exposure to feared stimuli is widely considered an empirically-supported principle of behavior change for anxiety disorders (Lohr, Lilienfeld, & Rosen, 2012). Exposure techniques are the cornerstone of CBT protocols for anxiety disorders, so much so that many debate if other treatment components add any incremental benefit above exposure alone (Barrera, Szafranski, Ratcliff, Garnaat, & Norton, 2016; Olatunji et al., 2010).

Given this evidence, why aren’t all mental health clinicians using exposure?

Despite the demonstrated efficacy of ET, many therapists do not use exposure therapy or use it only rarely (Becker, Zayfert, & Anderson, 2004; Freiheit, Vye, Swan, & Cady, 2004; Hipol & Deacon, 2013; Whiteside, Deacon, Benito, & Stewart, 2016). A key factor is lack of adequate dissemination of ET training. However, even when therapists indicate that they endorse a cognitive-behavioral orientation and have been trained in the use of exposure therapy methods, many report they do not utilize these methods or use them only infrequently. Given the established efficacy of exposure treatments for anxiety disorders, it is critical that we expand efforts to understand how to increase implementation of exposure techniques.

Another concerning factor related to the implementation of ET is the research that has found that even among therapists who report using exposure techniques, many do not deliver them in an optimal manner. Therapists in community settings appear to utilize client-directed exposure substantially more than therapist-directed exposure (Freiheit et al., 2004; Hipol & Deacon, 2013), which is concerning given indications that self-directed exposure is less effective (Abramowitz, 1996). Additionally, although findings suggest that effective exposure treatment requires its delivery in a prolonged, repeated, and intense manner, many therapists also endorse promoting arousal reduction techniques (e.g., deep breathing exercises) during exposure, despite theoretical and empirical contraindications for doing so (Blakey & Abramowitz, 2016; Schmidt et al., 2000). For example, Deacon and colleagues (2013) found that many therapists delivering interoceptive exposure for panic disorder utilized controlled breathing strategies during delivery, which have shown no benefit in treatment and stand in direct contrast to the prolonged and intense delivery suggested by validated treatment manuals.

Given the efficacy of exposure therapies for anxiety disorders, it is critical to examine the reasons behind underutilization and improper use of these methods. Many factors are likely to impede dissemination and effective implementation, including lack of adequate training, persistent beliefs that empirically-supported treatments conducted in research settings are irrelevant to clinical practice, therapists’ overemphasis on clinical intuition, and therapist concerns about exposure therapy (Deacon & Farrell, 2013).

What do we do about this?

Research must determine how to improve the implementation of exposure therapy through clinical training. Further investigation onto the barriers to dissemination and effective training will provide guidance about how to achieve these goals. Mental health clinicians clearly desire more training in exposure therapy. However, the question remains: which training method will prepare clinicians to deliver the most effective exposure therapy?

Abramowitz, J. S. (1996). Variants of exposure and response prevention in the treatment of obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 27(4), 583-600.

Bandelow, B., Reitt, M., Röver, C., Michaelis, S., Görlich, Y., & Wedekind, D. (2015). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 30(4), 183-192.

Barrera, T. L., Szafranski, D. D., Ratcliff, C. G., Garnaat, S. L., & Norton, P. J. (2016). An Experimental comparison of techniques: Cognitive defusion, cognitive restructuring, and in-vivo exposure for social anxiety. Behavioural and Cognitive Psychotherapy, 44(2), 249-254.

Becker, C. B., Zayfert, C., & Anderson, E. (2004). A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3), 277-292.

Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1-15.

Deacon, B. J., & Abramowitz, J. S. (2004). Cognitive and behavioral treatments for anxiety disorders: A review of meta‐analytic findings. Journal of Clinical Psychology, 60(4), 429-441.

Deacon, B. J., & Farrell, N. R. (2013). Therapist barriers to the dissemination of exposure therapy. In Handbook of treating variants and complications in anxiety disorders (pp. 363-373). New York: Springer.

Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J., Sy, J. T., Zhang, A. R., & McGrath, P. B. (2013). Assessing therapist reservations about exposure therapy for anxiety disorders: The Therapist Beliefs about Exposure Scale. Journal of Anxiety Disorders, 27(8), 772-780.

Freiheit, S. R., Vye, C., Swan, R., & Cady, M. (2004). Cognitive-behavioral therapy for anxiety: Is dissemination working?. The Behavior Therapist, 27(2), 25-32.

Hipol, L. J., & Deacon, B. J. (2013). Dissemination of evidence-based practices for anxiety disorders in Wyoming A survey of practicing psychotherapists. Behavior Modification, 37(2), 170-188.

Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: a review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.

Lohr, J. M., Lilienfeld, S. O., & Rosen, G. M. (2012). Anxiety and its treatment: Promoting science-based practice. Journal of Anxiety Disorders, 26(7), 719-727.

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

Newby, J. M., McKinnon, A., Kuyken, W., Gilbody, S., & Dalgleish, T. (2015). Systematic review and meta-analysis of transdiagnostic psychological treatments for anxiety and depressive disorders in adulthood. Clinical Psychology Review, 40, 91-110.

Olatunji, B. O., Cisler, J. M., & Deacon, B. J. (2010). Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings. Psychiatric Clinics of North America, 33(3), 557-577.

Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits, J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analysis of treatment outcome and moderators. Journal of Psychiatric Research, 47(1), 33-41.

Richard, D. C. S. & Lauterbach, D. L. (2007). Handbook of exposure therapies. Boston: Academic Press.

Schmidt, N. B., Woolaway-Bickel, K., Trakowski, J., Santiago, H., Storey, J., Koselka, M., & Cook, J. (2000). Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining. Journal of Consulting and Clinical Psychology, 68(3), 417-424.

Whiteside, S. P., Deacon, B. J., Benito, K., & Stewart, E. (2016). Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders. Journal of Anxiety Disorders, 40, 29-36.

Published September 2, 2017

Migraine: The Hopeful Disorder

Tue, 30 Aug 2016 13:47:24 GMT

Ronald S. Kaiser, PhD, ABPP - Jefferson Headache Center, Thomas Jefferson University

The American Migraine Prevalence Study (Lipton et al, 2007), the largest study of migraine in America ever conducted, found that 12% of Americans have migraine, and 90% of them can’t function normally on days when they have migraine. 30% of them are bedridden on those days. Obviously, that level of impairment impacts quality of life as well as mood.

Working with migraine headache patients can be challenging, but it can also be one of the most rewarding therapeutic experiences that can occur for both the patient and the therapist – so long as each pursues the therapeutic process with the proper mindset. Because of the size of the migraine population, there has been considerable research to provide guidance for understanding and treating migraine patients.

Reviews of the literature (Kaiser et al, 2015, Kaiser et al, 2016), as well as clinical experience, provide principles for psychotherapeutic effectiveness in treating migraine patients.

In almost every case, migraine is a neuro-biochemical disorder that may include pain, nausea, light and sound sensitivity, and fatigue. Various brain chemicals have been implicated in the migraine process including serotonin, norepinephrine, and calcitonin gene-related peptide (CGRP). Unlike many other types of pain patients whose pain is caused by structural damage (e.g., herniated or bulging discs, diabetic neuropathy), improved control over physiology can lead to lasting changes. Thus, migraine patients don’t have to assume that “living with the pain” is as good as it can get. Some individuals are currently disabled or otherwise impaired by their head pain, but it is important to be mindful of the fact that MIGRAINE PATIENTS CAN GET BETTER.
The term, migraine, is not a description of the degree of impairment that the patient may be experiencing. Since most people have had headaches, some of which have been accurately or inaccurately described as migraine, there is a good chance that the therapist working with the migraine patient has had headaches him/herself. It is important to not assume that the patient’s experience is the same as that of the therapist. Listen to the patient’s description of pain and also ask about associated symptoms.
Appropriately diagnosed migraine is neither a terminal illness nor the type of disorder that deteriorates organs, but it does negatively impact upon quality of life. Migraine can reduce or severely limit productivity at school or work, curtail social involvements, affect family relationships, and cause the patient to feel physically and emotionally drained even when overtly functioning in a successful manner.
Migraine patients don’t wear badges such as casts, walkers, etc. Because they look “normal”, many have had to deal with the stigma of being seen as having weakness, hypochondriasis, drug-seeking behaviors, and secondary gains (Young et al, 2013). To cope with being stigmatized, patients may develop counterproductive coping strategies. McCrea et al (2013) found that such patients developed a dislike for interacting with others, while Waugh et al (2014) found that internalized stigma had a negative relationship with self-esteem and pain self-efficacy – even when controlling for depression. In many cases, stigmatizers have included medical and mental health professionals as well as family members, friends, and coworkers. Until proven otherwise, the patient may not trust your ability to be empathic.
Without proper guidance, many headache patients develop their own coping strategies – with differing degrees of appropriateness and effectiveness. In some cases, they may overuse medications for pain in order to keep functioning. Some patients withdraw from normal activities for fear of aggravating their headaches, and they become physically and emotionally deconditioned and depressed. Others have mastered the art of being a migraine patient – treating the migraine as part of life, but not part of the definition of self.

For the therapist, there can be no better patient than a motivated headache patient. Regardless of the patient’s current means of coping, there usually is a history of success that can be called upon. There is the probability of getting better, and there usually are some bad habits that can be changed to reduce the centrality of the headache. When migraine patients feel they are being understood, they typically become willing allies in their treatment.

If the patient is getting appropriate medical treatment, the therapist is part of a treatment team. Long before integrated care became a buzzword, cooperation between physicians and mental health professionals was taking place in the field of headache medicine

There have been many psychological approaches to migraine treatment. Although some appear to be promising, such as acceptance and commitment therapy (ACT), mindfulness, neurofeedback, and yoga, there are four approaches that have attained an “A” rating from the U.S. Headache Consortium: relaxation training; thermal biofeedback plus relaxation training; EMG biofeedback; and cognitive-behavioral therapy (CBT) (Silberstein, 2000).

Because of its focus upon the thinking process as an agent of change, CBT is particularly well-suited to working with headache patients whose typically good cognitive functioning enables them to be active participants in their treatment plans (Kaiser & Weatherby, 2009). In addition, while both anxiety and depression significantly affect headache-related quality of life (HRQoL), catastrophizing has been found to be an independent and greater predictor of HRQol – as it intensifies the negative aspect of pain and exaggerates helplessness (Holroyd et al, 2007). Of course, a major focus of CBT is the reduction of catastrophic thinking.

The positive focus utilized in working with migraine patients has led to the widespread incorporation of positive psychology techniques in the treatment process. Goal-Achieving Psychotherapy (GAP), a unique offshoot of CBT and positive psychology, was developed, based upon strategies that have been successfully implemented to promote positive behavior change at the Jefferson Headache Center in Philadelphia (Kaiser, 2012).

Certain principles have emerged in our work that can be helpful in guiding the mental health professional in working with migraine patients.

Any patient with chronic and/or debilitating migraine needs to be under the care of a knowledgeable and supportive physician who has done an appropriate evaluation to determine whether we are dealing with a primary migraine disorder or whether the patient’s pain is secondary to a medical condition that has to be addressed differently.
As with any therapy patient, a comprehensive history should be taken to determine whether, instead of dealing with a primarily medical disorder, we are dealing with a symptom of a complicated psychological issue that requires special attention - such as past trauma or severe psychopathology such as a delusional disorder or dissociation.
Because migraine patients often have a history of being misunderstood, marginalized, and stigmatized, therapeutic empathy is particularly important in working with this population.
Migraine-oriented treatment needs to be positive, forward looking, and active. Homework assignments provide a system for measuring progress.
While CBT is an effective treatment modality, it is important to not just address negative thoughts and irrational statements, but also to quickly get the patient into a positive mindset by addressing what can go right.
Research is quite clear in reflecting the fact that positive change and progress in three main areas - health and fitness, intellectual functioning, and social functioning - is associated with achievement and happiness (Achor, 2010). Working on improving one’s body, mind, and character is incompatible with spending an inordinate amount of time focusing upon one’s pain. Goals for improvement need to be realistic and individually designed to maximize chances for success.
Incorporating techniques such as biofeedback, meditation, and yoga can aid the patient in gaining a sense of control over seemingly involuntary aspects of physiology. Techniques that can help regulate physiology may have the added side-effect of helping migraine patients reduce or wean from their medications over time.
Speaking of medications, it is important for the therapist working with migraine patients to be aware of the range of effective preventive and abortive medications that utilized to treat migraine as well as being knowledgeable of guidelines for their use. Conversely, it important to recognize which medications should not be used. Because we are not trying to promote the notion of indefinitely living with pain, headache physicians discourage excessive use of pain medications, especially opioids. Even the daily use of over-the-counter analgesics can cause changes in physiology that interfere with the potential for effective headache control.
It is not accidental that a physical and socially bonding activity has evolved as a centerpiece of the migraine awareness movement. Now taking place in several cities, Miles for Migrainerun/walk events enable migraine patients, family members, health care professionals, and other supporters to live the message that migraine needs to be confronted proactively rather than reacted to in a passive manner. It is part of good mental health treatment for the therapist to encourage patients to participate in such physical activities at a level consistent with their abilities. In addition, monies raised from Miles for Migraine events support research and public awareness of migraine – enabling patients and their supporter to be actively involved in reducing the stigma of migraine and ultimately achieving control over the disease.

Despite all the progress that has been made, migraine is a stubborn disorder that does not always respond to appropriate medical treatment. Treating migraine is a process. Neither the patient nor the therapist can expect it to follow the type of predictable course that people have learned to expect from a bout with the flu or the recovery following a surgical procedure. Patience is required, and sometimes it is required for a pretty long time. Being active, however, reduces the centrality of the migraine in the patient’s life. Progress in making positive changes that affect body, mind, and character provide the evidence that change can occur – as can the recognition that, once the bad stuff has been ruled out, we are working on a potentially solvable problem. The therapist’s role includes being a cheerleader for change because, indeed, MIGRAINE PATIENTS CAN GET BETTER.

Achor, S. (2010). The happiness advantage. New York: Crown.

Holroyd, K., Drew, J., Cottrell, C., Romanek, K., & Heh, V. (2007). Impaired functioning and quality of life in severe migraine: The role of catastrophizing and associated symptoms. Cephalalgia, 27(10), 1156-65.

Kaiser, R. (2012). Goal-achieving psychotherapy. Retrieved from wwww.thementalhealthgym.com/goal-achieving-psychotherapy.

Kaiser, R., Kurzyna, A., & Mooreville, M. (in press). Psychological factors and headache. Medlink Neurology.

Kaiser, R., Mooreville, M., & Kannan, K. (2015) Psychological interventions for the management of chronic pain: A review of current evidence. Current Pain and Headache Reports, 9, 43. doi: 10.107/s11916-015-0517-9.

Kaiser R, & Weatherby S. (2009). Psychology in headache management. In: Kernick D, Goadsby PJ (eds). Headache: A practical manual. Oxford: Oxford University Press, 248-251.

Lipton,R., Stewart, W., Diamond, S., Diamond,M., & Reed, M. (2001). Prevalence and burden of migraine in the United States: Data from the American migraine study II. Headache, 61, 646-657.

McCrea, S, Kaiser, R., & Young, W. (2014) The relationship between personality factors and perceptions of stigma in chronic and episodic migraine patients. Headache, 54, :59.

Silberstein, S. (2000) Practice parameter: Evidence-based guidelines for migraine headache (an evidenced-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology, 55(6), 754-762.

Waugh, O., Byrne, D., & Nicholas, M. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 1-10.

Young, W., Park, J., Tian, I., & Kempner, J. (2013). The stigma of migraine. Plos One. Retrieved from dxdoi.org/10.1371/journal.poneoo54074

Published August 30, 2016

CBT for GI Disorders

Thu, 28 Jul 2016 13:49:18 GMT

Melissa Hunt, PhD - University of Pennsylvania Department of Psychology

People with chronic GI disorders fall into two large categories – those with functional disorders like Irritable Bowel Syndrome (IBS) and those with disorders in which tissue pathology and other pathognomic indicators can actually be identified, like the Inflammatory Bowel Diseases including Crohn’s and ulcerative colitis. Surprisingly, both groups can benefit enormously from cognitive-behavioral therapy.

IBS is characterized by recurrent abdominal pain that is relieved by defecation, and is accompanied by abnormalities in the frequency and/or form of bowel movements (i.e. characterized by constipation, diarrhea or an alternating mix of the two.) In practice, individuals with IBS often experience urgency and develop a number of maladaptive coping strategies, most of which are designed to help them avoid visceral sensations and the possibility of needing to get to a bathroom urgently and not making it “in time.” Many people with IBS develop catastrophic cognitions about pain, about the possibility of incontinence and about the potential repercussions, both socially and occupationally, of needing the bathroom both frequently and urgently and not being able to “hold it.” Many people with IBS also develop considerable avoidance behaviors which can meet diagnostic criteria for agoraphobia. Avoidance can include many feared “danger” foods which are believed to “trigger” IBS “attacks” and avoidance of situations in which getting to a bathroom quickly and unobtrusively might be difficult. That includes numerous venues (malls, parks, stadiums, concerts, places of worship) and numerous situations (long drives, trains, planes, work environments that prohibit quick exits such as classrooms, reception, factory work, conference calls, and so on.) In many ways, IBS falls at the intersection of panic disorder with agoraphobia and social anxiety disorder, along with significant health anxiety and catastrophizing about both pain and other visceral sensations.

Fortunately, CBT is very well adapted to tackle both catastrophic cognitions and maladaptive avoidance behavior. Indeed, CBT is the intervention with the most empirical support in the treatment of IBS. With a little knowledge and minor adjustments, most CBT practitioners can probably address the concerns of IBS patients. First, one should always start with a good assessment, including coordination of care with medical providers in order to review the patient’s medical history and the various diagnostic procedures they have undergone. In most cases, the diagnostic tests will all have been negative. If the patient has not been tested for celiac disease (an autoimmune disorder that leads to true gluten intolerance), they should be, as this is an important differential medical diagnosis to rule out. However, extensive, invasive testing, including colonoscopy and endoscopy is not recommended by current medical guidelines , unless the patient has “alarm” symptoms (such as blood in the stool, inflammatory markers in the blood or stool, fever, nutrient deficiencies or unexplained weight loss) that may signal an underlying inflammatory process (Brandt et al., 2009). The next step is psychoeducation about how stress can result in sympathetic nervous system arousal and reduced parasympathetic autonomic activity that directly affect the gut. This is important because it provides the rationale for relaxation training and stress management strategies like cognitive restructuring and CBT more generally. Next comes relaxation training, especially deep diaphragmatic breathing, which has been shown to optimize GI motility, as well as sympathovagal balance and heart rate variability.

Once the patient has a better grasp on the relationship between stress, distress and GI discomfort and is using deep breathing (and/or other strategies including mindfulness, imagery, progressive muscle relaxation and so on) effectively, the therapist can move on to the basic CBT model, introducing the notion that beliefs (not situations) affect our emotions and that beliefs can be right or wrong. This is all standard CBT fare (thought records, benign alternatives, evaluating evidence) but will often have to focus on situations in which the person’s gut is acting up. Behavioral experiments are an important part of this process. For example, send the patient to a movie theater or house of worship, have them sit in the very back, and count how many people actually get up at some point to leave and then come back. They will be surprised by how often this happens and how little most people react.

Finally, in vivo exposure therapy that reduces behavioral avoidance is a crucial part of every successful treatment for IBS. This may need to include food (hint – there are no “danger” foods), food-related situations, abdominal sensations, and any situation the person avoids for fear of not being able to get to a bathroom in time. Using standard in-vivo exposure strategies (e.g. constructing a fear hierarchy and working up it using graded exposure) works quite well. For example, if the person is afraid of long car trips, have them sit in the car in their driveway for 30 minutes. Then progress to driving around the block near their home 20 times. Then drive a mile away and drive back. At home, when they feel the urge to defecate, see if they can delay going to the bathroom for 1 minute. After mastery of 1 minute then try increasing the duration of time (2,3…5 minutes) so the person learns that they can indeed “hold it” without experiencing incontinence. Such exposure can be a huge confidence booster.

Another important area to target is “subtle” avoidance, especially use of a pharmacopeia of medications including anti-diarrheal agents, anti-gas agents and antacids. Patients will often insist that it is perfectly rational and sensible to use these medications, but further probing will often reveal that they are using them in maladaptive ways that perpetuate the cycle of anxious avoidance. For example, if the person knows they have a stressful day coming up at work, they may take one or two Imodium before they even leave the house just in case. Many will recognize such safety behaviors as similar to those seen in people with panic disorder who use benzodiazepines PRN to fend off possible panic attacks. Whether or not the person also meets diagnostic criteria for anxiety disorders, this safety utilization behavior will maintain distress if not targeted in treatment. Moreover, while anti-diarrheal medications are quite safe, they can cause constipation and bloating and thus also perpetuate further avoidance and distress and maintain maladaptive beliefs. For example, people can become convinced that needing to poop is a catastrophe to be avoided at all costs. Turns out that getting people to stop using these medications on a regular basis is an important part of reducing GI specific catastrophic cognitions and visceral sensitivity, and ultimately it actually leads to reductions in abdominal discomfort and urgency.

Many IBS patients can benefit from a self-help book that makes this entire protocol accessible and easy to implement on their own. Reclaim Your Life from IBS: A Scientifically Proven Plan for Relief Without Restrictive Diets (available at Amazon or Barnes and Noble online) was tested in a randomized controlled trial and was shown to be quite effective (Hunt,Ertel, Coello, & Rodriguez, 2014). It can also be used as a treatment manual or guide for interested clinicians.

Unlike IBS, inflammatory bowel diseases lead to actual tissue damage and can have life threatening complications. They are auto-immune disorders that have a genetic basis and are probably related in part to disruptions in both the immune system itself and the microbiome of the gut. They are less prone to stress related exacerbations than IBS (Kovács & Kovács, 2007) but stress is still implicated in symptom exacerbation and relapse (Sajadinejad, Asgari, Molavi, Kalantari, & Adibi, 2002). In addition, CBT for GI disorders can have a very positive effect on health related quality of life, catastrophizing, visceral sensitivity and the secondary depression and anxiety that accompany many chronic and serious health conditions. CBT for IBDs varies somewhat from CBT for IBS, in that people may actually need to get to rest rooms urgently, may struggle with fecal incontinence, and may require significant medical management to target both the underlying inflammatory/auto-immune problems and the symptoms themselves. For individuals with IBDs, it is important to learn to distinguish between abdominal discomfort that can be safely ignored and abdominal pain that signals either a flare or a serious complication like a small bowel obstruction. There is a current trial ongoing at the University of Pennsylvania testing a self-help CBT protocol for IBD patients against an active psychoeducational control. If you know an IBD patient who might benefit from a GI informed approach to CBT, consider encouraging them to enroll in the trial. They can learn more at IBD-Study@psych.upenn.edu.

Brandt, L. J., Chey, W. D., Foxx-Orenstein, A. E., Schiller, L. R., Schoenfeld, P. S., Spiegel, B. M., & ... Quigley, E. M. (2009). An evidence-based position statement on the management of irritable bowel syndrome. The American Journal Of Gastroenterology, 104 Suppl 1S1-S35. doi:10.1038/ajg.2008.122

Hunt, M., Ertel, E., Coello, J., & Rodriguez, L. (2015). Empirical Support for a Self-help Treatment for IBS. Cognitive Therapy & Research, 39(2), 215-227. doi:dx.doi.org/10.1007/s10608-014-9647-3

Kovács, Z., & Kovács, F. (2007). Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease.International Journal Of Psychiatry In Medicine, 37(3), 245-255. doi:10.2190/PM.37.3.a

Sajadinejad, M. S., Asgari, K., Molavi, H., Kalantari, M., & Adibi, P. (2012). Psychological issues in inflammatory bowel disease: an overview. Gastroenterology Research And Practice, 2012106502. doi:10.1155/2012/106502

Published July 28, 2016

Painting a Picture of Evidence-Based Practice in Graduate Education

Sat, 23 Jul 2016 13:50:50 GMT

Michael Morrow, PhD - Arcadia University

Evidence-based practice (EBP) in clinical and counseling psychology is both an ethical and social justice imperative. Clients of all backgrounds deserve the psychosocial treatments most likely to benefit them and not cause harm (Lilienfeld, 2007). Accordingly, graduate programs are charged to provide students with sufficient preparation in EBP. Ideally, students should graduate their programs with a clear understanding of EBP, emerging skills in empirically supported assessments and treatments, and a firm commitment to maintaining an evidence-based orientation throughout their careers (Morrow, Lee, Bartoli, & Gillem, 2016). While graduates will undoubtedly require further training to master EBP, their education should plant the seeds needed to later bloom into competent evidence-based practitioners.

As a clinical psychologist (reared in a clinical science program) and a counselor educator, I am tasked with the privilege and challenge of helping MA-level counseling students begin their transformation into evidence-based practitioners, all in roughly three years of coursework and applied training. MA-level practitioners comprise the bulk of frontline mental healthcare in many communities (Weisz, Chu, & Polo, 2004); thus, it is critical to provide them with strong training in EBP. Over the past five years, I have learned that guiding students toward competence in EBP is no easy feat; in fact, simply helping them grasp the meaning of EBP is a major challenge, especially in light of the many misinterpretations that plague the field.

While definitions have evolved over time, EBP currently represents a broad framework for clinical decision making and service based on three key components: the strongest available research, clinical expertise, and client characteristics (e.g., preferences, strengths, and culture; Kazdin, 2008). When (and only when) these three components are thoughtfully and continually integrated throughout treatment, EBP occurs. Recent models also emphasize the role of the therapeutic relationship and other common factors (Ackerman et al., 2001).

Unfortunately, many students fail to internalize EBP as an overarching orientation and reduce it solely to using empirically supported treatments (ESTs): interventions supported by rigorous research for particular disorders (Norcross & Karpiak, 2012). While EBP involves using ESTs, it is a broader framework for decision making and intervention. This tendency to minimize EBP to ESTs is well documented (Luebbe, Radcliffe, Callands, Green, & Thorn, 2007) and poses a significant barrier to the proliferation of EBP. Creative teaching strategies are needed to ensure that students acquire a fuller and more accurate understanding of EBP.

Learning theory and research indicate that metaphors can be powerful teaching tools (Hansen, Richland, Baumer, & Tomlinson, 2011). Recently, I developed a metaphor to introduce EBP to counseling students. As a novice painter, I liken EBP to oil painting. I start by explaining that artists utilize a variety of tools (brushes, paint knives, and palettes) to mix and apply various materials (gesso, paint, and varnish); these tools and materials are analogous to practitioners’ knowledge and skills, including their competence in making evidence-based decisions, building strong therapeutic alliances, conducting and interpreting assessments, and delivering specific interventions (e.g., cognitive behavior therapy or exposure and response prevention).

I then add to the metaphor the adoption of an evidence-based orientation. Artists often begin oil paintings by covering the whole canvas with a wash of acrylic paint (e.g., a flat layer of light blue acrylic paint). While numerous layers of paint will be added atop, this wash provides an underlying tone for the entire piece (i.e., the blue wash will interact with each new layer of paint). This acrylic wash represents the adoption of an overarching evidence-based orientation, a guiding framework that colors key clinical decisions, such as choosing assessment tools, formulating conceptualizations, selecting treatment modalities, tailoring interventions, and monitoring progress. To illustrate this point, I ask students to visualize a blank treatment plan and imagine painting “EBP” in a light hue across the background (Figure 1).

Figure 1

Next, I add to the metaphor the process of utilizing research to guide treatment planning. Once the acrylic wash has dried, artists add their first layer of oil paint, which typically blocks out major forms (e.g., a flat grey patch denoting a mountain range) and creates a basic composition for the piece. Regarding EBP, this first layer reflects evidence from the best available research (Lilienfeld et al., 2013). When the research base is strong for treatments targeting a particular condition, it offers a very clear picture for treatment.

For instance, when working with a child with significant disruptive behavior, rigorous efficacy studies deem behavioral parent training a well-established intervention (Eyberg, Nelson, & Boggs, 2008). In this example, students can visualize themselves painting “behavioral parent training” atop a treatment plan already washed in a background of EBP (Figure 2). However, when research is lacking (e.g., ESTs for child Adjustment Disorders), it provides a much fainter picture of treatment. In these cases, practitioners must rely more heavily on the other components of EBP: clinical expertise and client characteristics.

Figure 2

I next introduce practitioners’ use of clinical expertise. Artists then add additional layers of oils and other materials (varnish, sand, stones) atop the previous layers to achieve various effects (detail, contrast, texture, depth, shine). Relative to EBP, these new layers reflect the integration of practitioners’ professional expertise to fill in any major gaps left uncovered by the extant research. In working with a child with an Adjustment Disorder, a practitioner could draw from her experience working with youth with this disorder or similar symptomology. If the child is presenting with a mix of internalizing symptoms, the practitioner could utilize well-established treatments (e.g., cognitive behavior therapies) for pediatric anxiety or depression.

Moreover, the final layers reflect practitioners’ efforts to incorporate client characteristics into treatment. In discussing this topic, it is critical to distinguish “modifying” and “tailoring” treatments. When modifying, practitioners alter treatment in a substantial way (e.g., removing elements or delivering components out of sequence). While such modifications can be justified (Lindhiem, Bennett, Trentacosta, & McLear, 2014), evidence-based practitioners are more likely to tailor by infusing client characteristics into the treatment framework (e.g., offering examples to match clients’ interests and building upon clients’ resources and values to help them reach their goals; Figure 3). This process reflects the notion of “breathing life” into an evidence-based protocol (Kendall, Chu, & Gifford, 1998), and, in my opinion, represents the precise point where the science and art of therapy intersect in the context of EBP.

Figure 3

Finally, I tack two remaining concepts onto the metaphor: progress monitoring and objective thinking. Artists frequently step back to view their work from afar (and from various angles). Similarly, evidence-based practitioners repeatedly examine clients’ progress by carefully monitoring changes in symptoms and behaviors. Stepping back to evaluate the full course of treatment offers invaluable information to further case conceptualization and treatment planning. Moreover, viewing a painting from different angles is analogous to considering alternate plausible hypotheses (e.g., reevaluating the primary factors maintaining a problematic behavior), which is critical to avoiding errors in clinical judgment (Spengler & Strohmer, 1994).

As paintings evolve with each brush stroke, the initial acrylic wash remains a unifying foundation for the entire work, just as an evidence-based orientation should guide the entire course of treatment. While I have experienced some success with this metaphor, I encourage other educators to develop their own based on their personal interests (e.g., sport, dance, music, cooking). Further, it would be helpful to start a field-wide dialogue on methods for teaching EBP, perhaps via a dedicated listserv or even an edited volume of different pedagogical approaches. Finally, I challenge all graduate instructors to guide their students to practice teaching others about EBP in order to prepare them to “carry the torch” from their education into the mental health landscape and paint their own pictures of EBP.

Ackerman, S. J., Benjamin, L. S., Beutler, L. E., Gelso, C. J., Goldfried, M. R., Hill, C., et al. (2010). Empirically supported therapy relationships: Conclusions and recommendations for the Division 29 Task Force. Psychotherapy: Theory, Research, Practice, Training, 38, 495-497.

Eyberg, S. M., Nelson, M. M., & Boggs, S. R. (2008). Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. Journal of Clinical Child & Adolescent Psychology, 37, 215-237.

Hansen, J., Baumer, E. P. S., Richland, L., & Tomlinson, B. (2011). Metaphor and creativity in learning science. Paper presented at the annual conference of the American Educational Researchers Association, New Orleans, LA.

Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63, 146-159.

Kendall, P. C., Chu, B., & Gifford, A. (1998). Breathing life into a manual: Flexibility and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5, 177-198.

Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70.

Lilienfeld, S. O., Lynn, S. J., Ritschel, L. A., Cautin, R. L., & Latzman, R. D. (2013). Why many practitioners are resistant to evidence-based practice in clinical psychology: Root causes and constructive remedies. Clinical Psychology Review, 33, 883-900.

Luebbe, A. M., Radcliffe, A. M., Callands, T. A., Green, D., & Thorn, B. E. (2007). Evidence-based practice in psychology: Perceptions of graduate students in scientist practitioner programs. Journal of Clinical Psychology, 63, 643-655.

Morrow, M. T., Lee, H., Bartoli, E., & Gillem, A. (2016). Strengthening counselor preparation in evidence-based practice. Submitted to the International Journal for the Advancement of Counseling.

Norcross, J. C., & Karpiak, C. P. (2012). Teaching clinical psychology: Four seminal lessons that all can master. Teaching of Psychology, 39, 301-307.

Spengler, P. M. & Strohmer, D. C. (1994). Counselor complexity and clinical judgment: Challenging the model of the average judge. Journal of Counseling Psychology, 41, 1-10.

Published July 23, 2016

Trial-Based Cognitive Therapy (TBCT): A New Evidence-Based Approach

Tue, 12 Jul 2016 13:56:17 GMT

Irismar Reis de Oliveira, MD, PhD - Professor of Psychiatry, Department of Neurosciences and Mental Health, Federal University of Bahia, Brazil

TBCT is a new branch of Beckian cognitive-behavior therapy (CBT) that organizes known standard CBT and behavioral techniques into a step-by-step fashion. In developing TBCT, my goal was to make CBT easily mastered by the therapist and more easily understood by the patients. TBCT should also be simpler to be implemented and maintain CBT’s recognized effectiveness and transdiagnostic feature (de Oliveira, 2015; 2016). A detailed case illustration may be found on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012a).

Inspiration for the development of TBCT came initially from the novel The Trial, by Franz Kafka (1925/1998). Although it was not the first time the courtroom metaphor was used in CBT – Freeman and DeWolf (1992), Cromarty and Marks (1995), and Leahy (2003) had already used this metaphor –, my idea was conceptualizing core beliefs (CBs) as self-accusations and giving all the columns of the traditional dysfunctional thought record (DTR) the courtroom connotation (de Oliveira, 2011). For instance, the column corresponding to the evidence confirming the CB would bring the prosecutor’s plea, and the evidence not supporting it would carry the defense attorney’s statements. The newly derived 7-column DTR, named trial-based thought record (TBTR; de Oliveira, 2008), contained several well-known traditional CBT techniques like the downward arrow approach (Burns, 1980), the sentence reversal procedure (Freeman and DeWolf, 1992), and the upward arrow technique (Leahy, 2003). A more detailed case illustration may also be downloaded on the Common Language for Psychotherapy Procedures website (de Oliveira, 2012b).

Several studies conducted in the last decade support the TBTR use in different psychiatric disorders (de Oliveira, 2008; de Oliveira, Duran, and Velasquez, 2012; de Oliveira, Hemmany, Powell, Bonfim, Duran, Novais, et al., 2012). For instance, TBTR was shown to decrease the credibility given by patients to dysfunctional negative CBs and the intensity of corresponding emotions in social anxiety disorder (de Oliveira, Powell, Caldas, Seixas, Almeida, Bomfim, et al. 2012; Powell, de Oliveira, Seixas, Almeida, Grangeon, Caldas et al. 2013). The conclusion reached by the above-mentioned studies was that TBTR might help patients reduce the credibility attached to the negative CBs and the intensity of corresponding emotions, regardless of the diagnosis.

New techniques were progressively added to the TBTR, resulting in TBCT. Such techniques were modifications of standard CBT and other approaches. Consequently, TBCT is an example of assimilative psychotherapy integration (Messer, 1992), in which various techniques from different theoretical origins are incorporated within the context of understanding provided by the home theoretical approach (Stricker, 2010). From the time of its original development, TBCT relied on Beckian CBT as the organizing theory, and subsequently added technical interventions drawn from several other approaches. Among them were Gestalt, compassion-focused therapy, metacognitive therapy, mindfulness, and Mitchell’s (1988) two-person relational model.

TBCT has its own case conceptualization, which makes it an individualized approach. It is divided into 3 levels and 3 phases, and includes a cyclic interactional mechanism in which components in each level influence the others, and flexibly allow the therapist to adapt the treatment to the individual’s features (de Oliveira, 2016).

Figure 1 depicts the three levels of information processing in the TBCT conceptualization diagram, and shows how a situation that is appraised in a biased fashion by the automatic thought (AT) elicits a dysfunctional negative emotion, which, in turn, produces undesired consequences in terms of behaviors and/or physiological responses. Figure 1 also contains arrows pointing back to the emotion, ATs and the situation, meaning that a confirmatory bias might preclude re-examination of the situation and replacement of the incorrect ATs with more functional and healthier perceptions (de Oliveira 2015; 2016).

Figure 1. TBCT case conceptualization diagram, phase 1, and its 3-level cognitive components: ATs, UAs and CBs. Here, dysfunctional negative CBs are predominantly active.

The TBCT case conceptualization diagram was also designed to help the patient realize that the behaviors that decrease anxiety and produce relief (e.g., avoidance) are little by little converted into coping strategies or safety-seeking behaviors, shown in Figure 1 as an arrow directed from the behavior and physiological response from the first to the second level on the right-hand side of the picture, meaning that situational perceptions in the first level (ATs) are progressively transformed into underlying assumptions (UAs) at the second level, which maintains and is maintained by the coping strategies/safety behaviors (de Oliveira, 2016). The table below shows the tools that were developed and are currently used during the TBCT therapy course.

Table 1. TBCT techniques and its diagrams. Column 2 informs the cognitive levels and column 3 informs in which sessions they are usually used (de Oliveira 2016).

The main TBCT technique used to restructure cognitions in the third level, namely CBs (Figure 1), is the TBTR. Besides including a courtroom metaphor, it introduces at least 12 known techniques usually used in CBT and listed below (de Oliveira, 2016):

Socratic dialogue;

Guided discovery;

Imagery re-scripting;

Empty chair or chairwork;

Downward arrow technique (investigation);

Evidence supporting the negative CB (prosecutor’s first plea);

Evidence not supporting the negative CB (defense attorney’s first plea);

Eliciting more automatic thoughts by discounting the positives (prosecutor’s second plea);

Sentence reversal (defense attorney’s second plea);

Upward arrow technique to uncover positive CBs (the defense attorney goes deeper);

Identifying cognitive distortions (jurors’ phase); and

The positive data log (preparation for the appeal), during which the patient summons the inner defense attorney as an ally to distance oneself even more and to collect daily elements that support the newly activated functional positive CBs.

In summary, TBCT is an evidence-based, three-level and three-phase Beckian branch of CBT, whose main techniques use the courtroom metaphor, and designed to facilitate the work of the therapist and the client by means of a highly structured (although flexible) protocol.

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de Oliveira, I.R. (2008). Trial-based thought record (TBTR): preliminary data on a strategy to deal with core beliefs by combining sentence reversion and the use of an analogy to a trial. Revista Brasileira de Psiquiatria, 30(1), 12–18.

de Oliveira, I.R. (2011). Kafka’s trial dilemma: Proposal of a practical solution to Joseph K.’s unknown accusation. Medical Hypotheses, 77(1), 5-6.

de Oliveira, I.R. (2012a) Trial-Based Cognitive Therapy. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2012b) Trial-Based Thought Record. Accepted entry in Common Language for Psychotherapy Procedures.

de Oliveira, I.R. (2015). Trial-Based Cognitive Therapy: A Manual for Clinicians. New York: Routledge.

de Oliveira, I.R. (2016) Trial-Based Cognitive Therapy: Distinctive Features. London:Routledge.

de Oliveira, I.R., Duran, E.P. and Velasquez, M. (2012). A trans-diagnostic observation of the efficacy of the Trial-Based Thought Record in changing negative core beliefs and reducing self-criticism. NEI Psychopharmacoloy Congress, San Diego, October 18-21.

de Oliveira, I.R., Hemmany, C., Powell, V.B., Bonfim, T.D., Duran, E.P., Novais, N. et al., (2012). Trial-based psychotherapy and the efficacy of trial-based thought record in changing unhelpful core beliefs and reducing self-criticism. CNS Spectrums, 17(1), 16–23.

de Oliveira, I.R., Powell, V.B., Caldas, M., Seixas, C., Almeida, C., Bomfim, T. et al. (2012). Efficacy of the Trial-Based Thought Record (TBTR), a new cognitive therapy strategy designed to change core beliefs, in social phobia: A randomized controlled study. Journal of Clinical Pharmacy and Therapeutics, 37(3), 328-334.

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Published July 12, 2016

Training and Supervision in CBT

Sun, 03 Jul 2016 14:01:12 GMT

Donna Sudak, MD - Drexel University College of Medicine

In the past twenty years there has been an enormous interest in the practice of cognitive-behavioral therapy (CBT). Substantial research has been conducted indicating that CBT is a significantly effective treatment for a variety of psychiatric illnesses. In 2001, the Residency Review Committee for Psychiatry adopted training requirements requiring competence in CBT for graduating psychiatry residents. In 2012, an inter-organizational task force produced guidelines for cognitive behavioral therapy training within doctoral Psychology programs in the United States (Klepac et al, 2012). Despite such requirements, dissemination of CBT remains poor (Shafran et al 2009) and training is lacking (Weissman et al, 2006). There is some evidence regarding specific methods of supervision and teaching that lead to effective application of CBT in clinical practice, but such evidence is even more poorly disseminated and inconsistently applied. Literature on the outcome of supervision is lacking. In spite of decades of emphasis on data-driven decision-making regarding the therapeutic process, there has been a relative lack of research to address questions of best practices in both training and supervision of CBT. Although dissemination of effective treatments for mental disorder is of paramount public health concern the field requires considerable progress to facilitate such dissemination.

There are at least two distinct points of view regarding therapist training represented in the training and supervision literature. First, a commonly articulated evidence-supported position is that more training produces more competent therapists (McManus et al 2010). A further assumption derived from this point of view is that more competent therapists have superior clinical outcomes. Several studies (Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006) support this view and point specifically to the role of supervision in producing competent therapists. Another argument, advanced from the public health perspective, is that the process of training and supervision is far too resource intensive to be practical for illnesses such as depression (Fairburn and Cooper 2011), which will soon represent the largest global disease burden (WHO). This perspective argues for a larger group of therapists trained in low intensity interventions for specific disorders along with guided self-help and internet assisted interventions to produce the widest ranging impact. Both ideas have merit, and likely an amalgam of training strategies will continue to be developed and tested worldwide.

Given the aforementioned scarcity of resources, identifying the most efficient strategies for supervision and training is imperative for the field. Regarding supervision, a small number of studies exist that indicate it improves therapist competence (Strunk et al 2010, Shlomskas et al 2005, Simons et al 2010, Bambling et al 2006), but do not describe the most efficient and effective procedures to follow. Even more significantly, the elements of what constitutes “adequate” supervision are only recently described in the literature and have been determined by a combination of narrative and systematic reviews and expert consensus (Milne and Dunkerley). The importance of adequate training for supervisors has led to several professional organizations establishing criteria for supervisors/trainers (e.g., the Academy of Cognitive Therapy, the British Association of Behavioural and Cognitive Psychotherapy) and/or required continuing education credits pertaining to supervision.

Key principles that are derived from CBT itself, because it is rooted in learning theory, are equally applicable to the supervisory process and facilitate therapist development. These include:

Make the terms of the supervisory relationship explicit and clear. Foster a relationship that promotes frank disclosure by the supervisee. Specific tools that may assist are handouts that teach the supervisee about how to use supervision, supervision contracts and a clear and open discussion of expectations and evaluation methods. Engagement in supervision is improved by a clear understanding of expectations of tape review and how to handle confidentiality and patient emergencies. Keep detailed supervision notes.
Structure supervision in a similar way to CBT. The process should reflect clinical practice because all the tools we use in therapy are designed to enhance learning. Supervision sessions optimally begin with agenda setting, check-in about last week’s session, then proceed to work on particular supervision questions, followed by summaries, feedback and homework. Socratic questions should be a mainstay of the work that you do. Require the use of rating scales to track patient progress.
Conceptualize the supervisee regarding particular learning needs, attitudes about psychotherapy, and culture. This will insure interventions that are tailored and precise.
Aim to use a variety of methods to promote learning in a supervision session. Keep your eye on the balance between challenge and support. The supervisee needs to have sufficient confidence in the relationship in order to frankly discuss patients and be sufficiently challenged to take the next learning step.
Identify what skill level is present in the supervisee either with direct observation of patient care or role-play practice in supervision. Train skills when necessary. If skill-training is not needed, be Socratic and help the supervisee think through and make decisions independently.
Examine actual work samples (therapy tapes) with a validated instrument, like the Cognitive Therapy Rating Scale (Young and Beck, 1980) to ensure progress is being made. Teach the supervisee to use the instrument as well. Such work provides valuable review of the key features of the session for the trainee.

These practices in supervision will help you be more effective at teaching the skills of therapy and make the work interesting to you both!

Bambling, M., King, R., Raue, P., Schweitzer, R., & Lambert, W. (2006). Clinical supervision: Its influence on client-rated working alliance and client symptom reduction in the brief treatment of major depression. Psychotherapy Research,16(3), 317-331.

Fairburn, C. G., & Cooper, Z. (2011). Therapist competence, therapy quality, and therapist training. Behaviour Research and Therapy, 49(6-7), 373-378.

Klepac, R. K., Ronan, G. F., Andrasik, F., Arnold, K. D., Belar, C. D., Berry, S. L., & ... Strauman, T. J. (2012). Guidelines for cognitive behavioral training within doctoral psychology programs in the United States: Report of the Inter-organizational Task Force on Cognitive and Behavioral Psychology Doctoral Education. Behavior Therapy, 43(4), 687-697.

McManus, F., Westbrook, D., Vazquez-Montes, M., Fennell, M., & Kennerley, H. (2010). An evaluation of the effectiveness of diploma-level training in cognitive behaviour therapy. Behaviour Research and Therapy, 48(11), 1123-1132.

Rakovshik, S. G., & McManus, F. (2010). Establishing evidence-based training in cognitive behavioral therapy: A review of current empirical findings and theoretical guidance. Clinical Psychology Review, 30(5), 496-516.

Sholomskas, D. E., Syracuse-Siewert, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We Don't Train in Vain: A Dissemination Trial of Three Strategies of Training Clinicians in Cognitive-Behavioral Therapy. Journal of Consulting and Clinical Psychology, 73(1), 106-115.

Simons, A. D., Padesky, C. A., Montemarano, J., Lewis, C. C., Murakami, J., Lamb, K., & ... Beck, A. T. (2010). Training and dissemination of cognitive behavior therapy for depression in adults: A preliminary examination of therapist competence and client outcomes. Journal of Consulting and Clinical Psychology, 78(5), 751-756.

Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: Predicting subsequent symptom change. Journal of Consulting and Clinical Psychology, 78(3), 429-437.

Weissman, M. M., Verdeli, H., Gameroff, M. J., Bledsoe, S. E., Betts, K., Mufson, L., & ... Wickramaratne, P. (2006). National survey of psychotherapy training in psychiatry, psychology, and social work. Archives of General Psychiatry, 63(8), 925-934.

Published July 3, 2016