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Groups 4 Health (G4H) is a group psychotherapy program that targets social group disconnection. An emerging evidence base supports its efficacy in reducing loneliness, depression, and social anxiety. However, to date there has been no formal analysis of its acceptability to clients and therapists, nor an investigation of its feasibility for wider implementation. This input from end users is crucial to ensure the program's wider suitability and to contribute to its improvement. This study drew data from three clinical trials, including 266 G4H clients and 68 G4H therapists. From the Phase III trial only, additional data were available from 90 clients in a dose-controlled cognitive-behavioral therapy (CBT) comparison group, and focus groups/interviews with 6 therapists and 13 clients. Client satisfaction was high, with all average ratingsgt;7/10, significantly exceeding the CBT comparison group. Therapist satisfaction with each module wasgt;5/7. Retention wasgt;80%. Homework completion was high, withlt;10% of clients saying that they had not attempted the homework. Therapists and clients both emphasized the benefits arising from G4H, and the contribution of the group context itself as a vehicle to achieve positive outcomes.

Sophisticated multicomponent treatments for adults with generalized anxiety disorder (GAD) have been developed over the past three decades. Although these comprehensive treatments have produced encouraging results, they appear to be less efficacious than treatments for other anxiety disorders. The goal of this randomized controlled trial is to test a newly developed, highly focused treatment for adults with GAD: Behavioral Experiments for Intolerance of Uncertainty. Sixty (60) participants (51 women, 9 men), with a mean age of 34.60 years (range: 19 to 67 years), were randomized to either treatment (n = 30) or wait-list control (n = 30). Treatment consisted of 12 weekly 1-hour sessions in which participants learned to use behavioral experiments to test their catastrophic beliefs about uncertainty. Assessments were conducted at pre-, mid- and postcondition, and at 6- and 12-month follow-up. The primary outcome was the severity of GAD, and secondary outcomes were worry, depression, somatic anxiety, and intolerance of uncertainty. Using growth curve modeling, we found that (1) the treatment group was superior to the wait-list group in terms of change from pre- to posttest on all outcomes; (2) the combined sample (once wait-listed participants received treatment) evidenced large and significant decreases on all outcomes; and (3) treatment gains were either maintained or increased over the 12-month follow-up period of the study. The new treatment is a promising treatment option for adults with GAD considering that it may be as efficacious as more comprehensive evidence-based psychological treatments for GAD.

Persistent somatic symptoms of varying etiology are very common in emerging adults and can lead to distress and impairment. Internet-delivered interventions could help to prevent the burden and chronicity of persistent somatic symptoms. This study investigated the impact of therapist guidance on the effectiveness of a cognitive-behavioral Internet intervention for somatic symptom distress (iSOMA) in emerging adults, as a secondary analysis of a two-armed randomized controlled trial. We included 149 university students (83.2% female, 24.60 yrs) with varying degrees of somatic symptom distress who were either allocated to the 8-week intervention with regular, written therapeutic guidance (iSOMA guided) or to the control group (waitlist), which was afterwards crossed over to receive iSOMA with guidance-on-demand (iSOMA-GoD). Primary outcomes were somatic symptom distress (assessed by the PHQ-15) and psychobehavioral symptoms of the somatic symptom disorder (assessed by the SSD-12) at pre- and post-treatment. Secondary outcomes included depression, anxiety, and disability. Both treatments showed statistically significant pre-post improvements in primary (iSOMA-guided: d = 0.86-0.92, iSOMA-GoD: d = 0.55-0.63) and secondary outcomes. However, intention-to-treat analysis revealed non-significant between-group effects for all outcomes (ps ≥ .335), after controlling for confounding variables, and effect sizes were marginal (d = -0.06 to 0.12). Overall, our findings indicate that Internet-delivered cognitive behavioral therapy with regular guidance is not unequivocally superior to guidance-on-demand in alleviating somatic symptom distress and associated psychopathology in emerging adults. As a next step, non-inferiority studies are needed to test the robustness of these findings and their impact on clinical populations.

Research has shown that generalized anxiety disorder is commonly associated with Chronic Fatigue Syndrome (CFS). This prospective cohort study aimed to investigate the prevalence of generalized worry in CFS patients and its relationship with fatigue, anxiety and social functioning, before and after Cognitive Behavioral Therapy (CBT). Our cohort consisted of 470 patients diagnosed with CFS who received CBT at a secondary care, specialist clinic. Patients completed self-report measures investigating levels of generalized worry, fatigue, work and social adjustment, anxiety and depression at baseline (pretreatment), discharge from treatment, 3-month and 6-month follow up (posttreatment). Analysis indicated a high prevalence of generalized worry (72.4%) at assessment. A significant reduction in worry following CBT (M = -3.42, p .001, 95% CIs: 2.26, 4.57) was observed at discharge, which remained stable at follow-up. Severe baseline worriers had greater overall fatigue score (M = 3.74, p = .026, 95% CIs: .33, 7.15) and worse overall work and social adjustment than mild worriers across time-points (M = 5.42, p = .035 95% CIs: .27, 10.58). Avoidance behavior mediated the association between generalized worry and work and social adjustment (95% bootstrap CIs: 013, .080). The majority of patients with CFS had comorbid generalized worry and severe worriers reported greater fatigue, anxiety, and worse work and social adjustment. This suggests that CFS patients may benefit from targeting generalized worry during CBT.

Body dysmorphic disorder (BDD) typically originates in adolescence and is associated with considerable adversity. Evidence-based treatments exist but research on clinical outcomes in naturalistic settings is extremely scarce. We evaluated the short- and long-term outcomes of a large cohort of adolescents with BDD receiving specialist multimodal treatment and examined predictors of symptom improvement. We followed 140 young people (age range 10-18) with a diagnosis of BDD treated at two national and specialist outpatient clinics in Stockholm, Sweden (n = 96) and London, England (n = 44), between January 2015 and April 2021. Participants received multimodal treatment consisting of cognitive behavior therapy and, in 72% of cases, medication (primarily selective serotonin reuptake inhibitors). Data were collected at baseline, posttreatment, and 3, 6, and 12 months after treatment.The primary outcome measure was the clinician-rated Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent version (BDD-YBOCS-A). Secondary outcomes included self-reported measures of BDD symptoms, depressive symptoms, and global functioning. Mixed-effects regression models showed that BDD-YBOCS-A scores decreased significantly from baseline to posttreatment (coefficient [95% confidence interval] = -16.33 [-17.90 to -14.76], p0.001; within-group effect size (Cohen's d) = 2.08 (95% confidence interval, 1.81 to 2.35). At the end of the treatment, 79% of the participants were classified as responders and 59% as full or partial remitters. BDD symptoms continued to improve throughout the follow-up. Improvement was also seen on all secondary outcome measures. Linear regression models identified baseline BDD symptom severity as a predictor of treatment outcome at posttreatment, but no consistent predictors were found at the 12-month follow-up. To conclude, multimodal treatment for adolescent BDD is effective in both the short- and long-term when provided flexibly within a specialist setting. Considering the high personal and societal costs of BDD, specialist care should be made more widely available.

Preliminary data suggest cognitive processing therapy (CPT) significantly reduces posttraumatic stress disorder (PTSD) symptom severity among military personnel and veterans when delivered over 12 days and combined with daily recreational activities (Bryan et al., 2018). The present study aimed to examine how therapy pace (i.e., daily vs. weekly sessions) and setting (i.e., clinic vs. recreational) impacts change in PTSD symptom severity. Forty-five military personnel and veterans diagnosed with PTSD chose to receive CPT (a) daily at a recreational facility with recreational programming, (b) daily on a university campus without recreational programming, and (c) weekly on a university campus without recreational programming. PTSD symptom severity was assessed with the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5). Reductions in CAPS-5 and PCL-5 scores were large and statistically significant across all three settings (Cohen's ds2.1). As compared to reductions in CAPS-5 and PCL-5 scores in daily therapy at a recreational facility (CAPS-5: d = 1.63-2.40; PCL-5: d = 1.99-2.17), reductions in CAPS-5 and PCL-5 scores were significantly larger in daily therapy on campus, CAPS-5: t(80) = -2.9, p = .005, d = 2.23-2.69; PCL-5: t(78) = 2.6, p = .010, d = 2.54-4.43, but not weekly therapy on campus, CAPS-5: t(80) = 0.2, p = .883, d = 1.04-2.47; PCL-5: t(78) = 1.0, p = .310, d = 1.77-3.44. Participants receiving daily therapy on campus and weekly therapy on campus also had higher rates of clinically significant improvement and good end-state functioning. Results support the effectiveness of CPT across multiple treatment settings and formats and suggest that daily CPT may be less effective when delivered in combination with recreational activities.

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M

A recent randomized controlled trial of group cognitive behavior therapy (CBGT) for perinatal anxiety showed that CBGT is effective in reducing anxiety and depression in pregnant and postpartum women. In secondary analyses, the role of potential mechanisms of symptom change was examined, including intolerance of uncertainty (IU), self-oriented parenting perfectionism (SOPP) and societal-prescribed parenting perfectionism (SPPP).The sample included 75 women (MTwo moderated mediation models were evaluated to identify potential mediators of the effect of condition (CBGT, waitlist) on anxiety (STICSA; Model 1) or depressive symptoms (EPDS; Model 2). In Model 1, changes in IU partially mediated the effect of condition on anxiety (STICSA) for both pregnant and postpartum women. Changes in SOPP and SPPP were partial mediators for postpartum women only. Change in depression (EPDS) was also a partial mediator for pregnant women in this model. In Model 2, none of the cognitive variables mediated the effect of condition on depressive symptoms (EPDS). However, change in anxiety (STICSA) was a significant mediator of the effect of condition on depression (EPDS) and only among pregnant women.The results provide support for IU, SOPP and SPPP as mechanisms of change during CBGT and identify differences in important mechanisms among pregnant and postpartum women.

Insomnia is highly prevalent among military veterans but access to cognitive behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28 to 55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a waitlist control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, post-treatment, and follow-up (12 weeks post-randomization), and app participants (n = 15) completed a qualitative interview at post-treatment. Findings suggest that Insomnia Coach is feasible to use, with three-quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at post-treatment, a larger proportion of Insomnia Coach (28%) than waitlist control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = -0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = -1.1, p = .001), sleep onset latency (d = -0.6, p = .021), global sleep quality (d = -0.9, p = .002), and depression symptoms (d = -0.8, p =.012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.

There is limited research on the concordance between client perceptions and clinician standards of the degree of symptom change required to achieve meaningful therapeutic improvement. This was investigated in an adult sample (N = 147) who received trauma-focused cognitive-behavioral therapies for posttraumatic stress disorder (PTSD). We examined whether clients' benchmarks of change were related to actual outcomes and the relationship between client expectations and their treatment outcomes. Clients completed measures indexing the level of symptom reduction required (in their view) to reflect a benefit or recovery from treatment and treatment expectations. Actual PTSD severity was indexed pre- and posttreatment via self-report and clinician-administered interview. Results demonstrated that the amount of change clients said they required to experience a benefit or recovery was significantly larger than typical clinical research standards. Nonetheless, the majority of client benchmarks of change (79.7-81.8%) were consistent with clinical research standards of what constitutes benefit or recovery. Client benchmarks were generally positively correlated with their actual outcomes. Clients' belief that treatment would be successful was associated with greater reductions in PTSD symptoms. These findings provide preliminary evidence that the standards used to determine clinically significant change are somewhat consistent with clients' own perceptions of required symptom change.

In the current study, we examined the degree to which sudden gains (large, rapid, and stable symptom reduction in a one-session interval) predicted treatment outcome in adults randomized to two different trauma-focused treatments. Adults diagnosed with PTSD were randomized to either written exposure therapy (WET; n = 63), a brief, exposure-based treatment for posttraumatic stress disorder (PTSD), or the more time-intensive Cognitive Processing Therapy (CPT; n = 63). Findings showed that 20.6% of participants who received WET and 17.5% of participants who received CPT experienced sudden gains. Sudden gains occurred earlier in WET (M session = 2.69, SD = 0.75) than in CPT (M session = 5.64, SD = 3.01). However, there were no treatment condition differences in the magnitude of the sudden gains. Treatment outcomes were significantly better for those who experienced sudden gains compared with those who did not, regardless of treatment assignment. Exploratory analyses of participants’ trauma narratives revealed that expressing more negative emotion predicted the occurrence of sudden gains in both treatment conditions. Negative beliefs about the self and others did not predict sudden gains. The findings are discussed in terms of how they may help identify individual early response patterns that predict outcomes in trauma-focused treatments.

Background: Cognitive models implicate interpretation bias in the development and maintenance of obsessive compulsive and related disorders (OCRDs), and research supports Cognitive Bias Modification for Interpretation (CBM-I) in targeting this mechanism. However, prior studies in OCRDs have been limited to nonclinical populations, adolescents, and adults in a laboratory setting. This study evaluated the feasibility and acceptability of CBM-I as an adjunctive intervention during intensive/residential treatment (IRT) for adults with OCRDs.Method: We modified a lab-based CBM-I training for adults seeking IRT for OCRDs, and conducted a feasibility trial (N = 4) and subsequent pilot RCT; participants (N = 31) were randomized to receive CBM-I or psychoeducation.Results: Benchmarks were met for feasibility, acceptability, and target engagement. From pre- to post-intervention, the CBM-I group showed a large effect for change in interpretation bias (d = .90), whereas this effect was trivial (d = .06) for psychoeducation.Conclusions: This was the first study to evaluate CBM-I in naturalistic treatment for OCRDs. Findings support the feasibility and acceptability of CBM-I in this novel sample and setting. A larger scale RCT is needed to determine whether CBM-I can enhance OCRD treatment response.

Although evidence demonstrated efficacy of cognitive-behavioral therapy (CBT) in adolescents with binge-eating disorder (BED), treatment response is heterogeneous. This study uniquely examined baseline predictors of symptom trajectories in N = 73 adolescents (12–20 years) with an age-adapted diagnosis of BED (i.e., based on objective and subjective binge-eating episodes). Based on evidence from adult BED, dietary restraint, overvaluation of weight/shape, and depressive symptoms were used to predict changes in abstinence from binge eating and eating disorder psychopathology after 4 months of individual, face-to-face CBT using growth models. Longitudinal trajectories of abstinence from objective and subjective binge eating and global eating disorder psychopathology assessed via the Eating Disorder Examination were modeled for five time points (pre- and posttreatment, 6-, 12-, and 24-month follow-up). Beyond significant, positive effects for time, no significant predictors for abstinence from binge eating emerged. In addition to significant decreases in eating disorder psychopathology over time, higher pretreatment dietary restraint and overvaluation of weight/shape significantly predicted greater decreases in eating disorder psychopathology over time. Consistent with research in adult BED, adolescents with higher than lower eating disorder-specific psychopathology especially benefit from CBT indicating that restrained eating and overvaluation of weight/shape may be BED-specific prognostic characteristic across developmental stages. Future predictor studies with an additional focus on potential age-specific predictors, such as family factors, and within-treatment processes may be critical in further evaluating treatment-related symptom trajectories in adolescent BED.

Despite growing attention towards the efficacy of culturally adapted cognitive-behavioral treatment (CBT) programs for children and adolescents, there is still little empirical and practical information available to therapists who adapt original treatment protocols to suit clients of a specific culture. The current study aimed to compare therapeutic interactions across CBT treatment delivered with two different cultural groups. We developed an observational coding system to examine behaviors exhibited by child, parent, and therapist during CBT sessions conducted in Australia and Japan for children with anxiety disorders. Our results demonstrated significant differences between the two countries with respect to the treatment readiness of children, the proportion of talking during the sessions by parents and children, therapists’ laughter, length of silence during the first session, and parent indices of accommodation. In terms of transitions over time (i.e., first to last CBT session), parents in both countries tended to talk more during the last CBT session, whereas only Australian therapists talked less over time. The proportion of silence decreased over time during the Japanese sessions, and the amount of interruptions by parents increased over time for Australian sessions. Finally, our exploratory analyses demonstrated that a number of behavioral observations were correlated with anxiety treatment outcome at post-treatment. This study suggests that interactions between a child, parent, and therapist during CBT sessions may be affected by the culture in which the CBT session occurs, which could have implications for culturally adapted CBT programs.

The current study employed machine learning to investigate whether the inclusion of observer-rated therapist interventions and skills in early sessions of psychotherapy improved dropout prediction beyond intake assessments. Patients were treated by postgraduate clinicians at a university outpatient clinic. Psychometric instruments were assessed at intake and therapeutic interventions and skills in the third session were routinely rated by independent observers. After variable preselection, an elastic net algorithm was used to build two dropout prediction models, one including and one excluding observer-rated session variables. The best model included observer-rated variables and was significantly superior to the model including intake variables only. Alongside intake variables, two observer-rated variables significantly predicted dropout: therapist use of feedback and summaries and treatment difficulty. Although not retained in the final prediction model, the observer-rated use of cognitive techniques was also significantly correlated with dropout. Observer ratings of therapist interventions and skills in early sessions of psychotherapy improve predictors of dropout from psychotherapy beyond intake variables alone. Future research could work toward personalizing dropout predictions to the specific dyad, thereby improving their validity and aiding therapists to recognize and react to increased dropout risk.

Anxiety control beliefs (i.e., beliefs regarding one’s ability to cope with external, fear-inducing threats and internal reactions to those perceived threats) have been found to negatively predict anxiety symptoms in children and adults and to be modifiable by cognitive-behavioral therapy for anxiety disorders. The current study examines whether changes in anxiety control beliefs were seen following a brief, intensive treatment for specific phobias, and whether those changes were associated with improvements in the targeted phobia and comorbid anxiety disorder symptoms. Participants were 135 children and adolescents (M age = 9.01 years, 49% male) who received one-session treatment (OST) with or without parental involvement for their primary specific phobia. Results indicated that self-reported anxiety control beliefs significantly increased following treatment and that these increases significantly predicted reductions in specific phobia severity and symptoms of comorbid anxiety disorders 6 months and 1 year following treatment. Findings illustrate that involvement in a single 3-hour OST was associated with changes in anxiety control beliefs and demonstrate the potential importance of targeting control beliefs in pediatric anxiety treatment.

Dropout from psychotherapy is common and can have negative effects for patients, providers, and researchers. A better understanding of when and why patients stop treatment early, as well as actionable factors contributing to dropout, has the potential to prevent it. Here, we examined dropout from a large randomized controlled trial of transdiagnostic versus single-diagnosis cognitive-behavioral treatment (CBT) for patients with anxiety disorders (n = 179; Barlow et al., 2017). We aimed to characterize the timing of and reasons for dropout and test whether participants who dropped out had different symptom trajectories than those who completed treatment. Results indicated that overall, the greatest risk of dropout was prior to the first treatment session. In single-diagnosis CBT, dropout risk was particularly elevated before the first session and after other early sessions, whereas in transdiagnostic CBT, dropout risk was low and stable before and during treatment. Participants most often dropped out due to failure to comply with study procedures or dissatisfaction with or desiring alternative treatment. Results from multilevel models showed that trajectories of anxiety symptoms did not significantly differ between dropouts and completers. These findings suggest that there may be specific time windows for targeted and timely interventions to prevent dropout from CBT.

Although technical (quality of delivering techniques from a specific treatment) and global (general clinical expertise) competence are believed to be important ingredients of successful psychosocial treatment with youth, there have been few empirical efforts to measure both dimensions. Efforts to understand the role that each competence dimension plays in the process and outcome of youth treatment starts with determining whether the dimensions can be measured separately. This study examined whether scores from measures designed to assess technical and global competence were distinct. Treatment sessions (N = 603) from 38 youths (M age = 9.84 years, SD = 1.65; 60.5% White; 52.6% male) treated for primary anxiety problems within a randomized effectiveness trial were coded. Four coders used observational measures designed to assess technical competence, global competence, protocol adherence, and the alliance. Mean item interrater reliability was .70 (SD = .09) for technical competence and .66 (SD = .05) for global competence. While most components of global competence were distinct from technical competence scores, two components showed redundancy (r > .70). Scores on both competence measures were empirically distinct (r < .70) from scores on measures of protocol adherence and the alliance. Although the measures did not fully distinguish between technical and global competence, our findings do indicate that some components of technical and global competence may provide unique information about competence.

Provoked vestibulodynia is a vulvar pain condition causing sexual dysfunction, affecting 8% to 10% of women. Our recently published randomized clinical trial (N = 108 couples) found that cognitive behavioral couple therapy (CBCT) and topical lidocaine reduced women's pain and associated sexual symptoms, with CBCT showing more benefits. Little is known about pretreatment predictors of treatment outcomes in couples sex therapy. In the current study, we examined women and their partners' pretreatment demographic (age, relationship length), clinical (pain duration, anxiety) and interpersonal (partner responses to pain, sexual goals) predictors/moderators of women's pain intensity, pain unpleasantness, and sexual function at posttreatment and 6-month follow-up. Longer relationship duration, lower anxiety in women, partner higher solicitousness and partner higher approach sexual goals predicted better pain outcomes for women with PVD irrespective of treatment condition. CBCT was more effective than lidocaine for improving women's sexual function at posttreatment when, at pretreatment, women had partners with higher anxiety and women reported lower approach sexual goals, whereas lidocaine was more effective for improving women's sexual function at follow-up when partners had higher approach sexual goals. Findings can assist clinicians in determining what treatment will be most beneficial for whom.

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.

Cognitive behavioral therapy (CBT) of depression is hypothesized to achieve its effects by correcting negative biases. However, little research has tested how biases change over the course of CBT. We focus on biases in interpersonal judgments and examine whether changes in biases occur in CBT and are associated with symptom improvements. A sample of 126 adults (60% women, mean age 31.7, 83% White) participated in CBT of depression. Observers provided ratings of patients participating in two interpersonal tasks on three occasions. Patients were asked to predict observers’ ratings. In a thin slice (TS) task, observers evaluated how patients came across in a brief segment in which patients talked about themselves. In a Standard Interaction Task (SIT), observers rated the social skills patients displayed in challenging role plays. The difference between patient predictions and observer ratings provided measures of bias in these interpersonal judgments. TS and SIT bias became significantly less pessimistic and more realistic over the course of CBT. Improvements in TS bias were associated with a faster reduction in symptoms, whereas there was a non-significant trend for improvement in SIT bias being associated with faster symptom reduction. Consistent with the CBT model, negative interpersonal biases became more realistic throughout a course of CBT for depression and at least some of the changes in bias were related to therapeutic outcomes. We encourage future researchers to continue examining for whom and under which conditions correcting such biases produces the greatest benefits.

Homework assignments are an integral part of cognitive behavioral therapy, providing patients with opportunities to practice skills between sessions. Generally, greater homework compliance is associated with better treatment outcomes. However, fewer studies have examined the effect of homework quality on treatment outcomes. This study examined homework compliance and quality as predictors of outcome and attrition across five CBT protocols. A sample of 179 individuals with principal diagnoses of generalized anxiety disorder, panic disorder, social anxiety disorder, or obsessive-compulsive disorder were randomized to receive a transdiagnostic CBT protocol (the Unified Protocol) or a single-diagnosis CBT protocol corresponding to their principal diagnosis. The Unified Protocol had a lower homework burden than the majority of the single-diagnosis protocols, which varied in degree of assigned homework. Despite this, there were no differences in average homework compliance or quality across principal diagnosis, treatment condition, or their interaction. Homework quality was significantly related to all symptom outcomes (self-reported and clinician-rated anxiety and depressive symptoms, clinician-rated clinical severity). Homework compliance was significantly related to clinician-rated anxiety symptom outcomes. Additionally, greater homework quality and compliance were both significantly associated with increased odds of completing treatment, suggesting homework variables can be useful and easily obtainable predictors of treatment retention.

Although clinical intuitions influence psychotherapeutic practice and are a rich source of novel hypotheses for research, many remain to be empirically tested. This study evaluates whether clinicians’ beliefs about barriers to progress in cognitive-behavioral therapy (CBT) for panic disorder are supported by data. Data from a randomized-controlled trial comparing CBT to panic-focused psychodynamic psychotherapy (PFPP) for adults with primary panic disorder (N = 161) were used to evaluate 15 factors endorsed by clinicians as impediments to CBT in a recent survey. Panic severity was assessed before, during (at Weeks 1, 5, and 9), and at termination of treatment (Week 12) using the Panic Disorder Severity Scale. Hierarchical linear modeling revealed that none of the perceived barriers were predictive of poor outcome. Contrary to clinicians’ intuitions, dissociation during panic attacks was associated with greater symptomatic improvement in both treatment arms (β = −0.69, p < .05), above the effect of established predictors. Moderation analyses revealed that when patients had PTSD diagnosed with the Anxiety Disorders Interview Schedule (β = 1.71, p < .05) or less severe panic disorder (β = 0.45, p = .04), they changed more rapidly in CBT than in PFPP. Overall, clinician agreement was inversely related to the strength of a predictor (r = −.24, p = .39). Although clinical intuitions can be useful as clinical and empirical signals, such beliefs should be critically examined before informing practice. Dialogue between academics and clinicians might be enhanced through research that incorporates input from front-line practitioners.

Exposure-based therapies for posttraumatic stress disorder (PTSD) and anxiety disorders remain underutilized, despite their effectiveness and widescale dissemination efforts. This study surveyed a broad range of licensed providers (N = 155) to examine rates at which prolonged exposure (PE) and other interventions are used to treat PTSD and to investigate provider characteristics linked to exposure beliefs and utilization. While 92.3% of clinicians reported understanding of or training in exposure, only 55.5% of providers reported use of PE to treat PTSD. Clinicians with current cognitive behavioral therapy (CBT) orientation, CBT training orientation, a doctoral degree, and training in PE endorsed greater likelihood of exposure utilization for PTSD (ps < .001, ds = 0.82-1.98) and less negative beliefs about exposure (ps < .01, ds = 0.55-2.00). Exposure beliefs also differed based on healthcare setting (p < .001). Among providers trained in exposure (n = 106), master's degree and non-CBT current theoretical orientation were associated with high utilization yet also negative beliefs. Results suggest exposure training, accurate beliefs, and utilization still lag among some groups of providers. Additionally, negative beliefs and misunderstanding of the exposure rationale may persist even among providers who are trained and report high utilization.

This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and post-treatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach—and less use of accommodation, unrelated talk, and externalizing language—predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher ‘total dose’ of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the “black box” of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.

We examined the outcomes of individual cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) in a sample of 93 adults seeking treatment in a university outpatient clinic specializing in CBT for SAD. Treatment followed the structure of a manual, but number of sessions varied according to client needs. After approximately 20 weeks of therapy, patients' social anxiety had decreased and their quality of life had increased. Patients with more severe SAD or comorbid major depressive disorder (MDD) at pretreatment demonstrated higher levels of social anxiety averaged across pre- and posttreatment. However, clinician-rated severity of SAD, comorbid MDD, or comorbid generalized anxiety disorder did not predict treatment outcome. Higher pretreatment scores on measures of safety behaviors and cognitive distortions were associated with higher social anxiety averaged across pre- and posttreatment and predicted greater decreases from pre- to posttreatment on multiple social anxiety outcome measures. We found no predictors of change in quality of life. Those with high levels of safety behaviors and distorted cognitions may benefit more from CBT, perhaps due to its emphasis on targeting avoidance through exposure and changing distorted thinking patterns through cognitive restructuring methods. Our study lends support to the body of research suggesting that manualized CBT interventions can be applied flexibly in clinical settings with promising outcomes for patients over a relatively short course of therapy.

Internet-based acceptance and commitment therapy (iACT) primarily targets the process of psychological flexibility. Its accessibility and low-intensity delivery are applicable across different treatment and prevention scenarios. This transdiagnostic meta-analysis reviews the effectiveness of iACT on anxiety, depression, quality of life, and psychological flexibility across individuals with different psychological and somatic conditions/complaints, or undiagnosed complaints. Seven databases were searched for randomized controlled trials that reported on anxiety, depression, quality of life, and psychological flexibility outcomes from iACT in any adult population. Engagement with iACT was summarized and methodological and population-related variables were investigated as potential moderators of effectiveness. Across 25 studies, small pooled effects were found for all outcomes at post-assessment and maintained at follow-up time-points. Interventions with therapist guidance demonstrated greater effectiveness in improving depression and psychological flexibility outcomes compared to nonguided iACT, and populations defined by a psychological condition or symptoms (e.g., depressed samples) demonstrated greater improvements in anxiety compared to nonclinical or somatic populations (e.g., chronic pain samples or students). Participants completed on average 75.77% of iACT treatments. While we found iACT to be effective in improving and maintaining mental health outcomes across diverse populations, there was limited evidence of reliable, clinically significant effects. PROSPERO registration number: CRD42020140086.

Although patient intelligence may be an important determinant of the degree to which individuals may comprehend, comply with, and ultimately benefit from trauma-focused treatment, no prior studies have examined the impact of patient intelligence on benefit from psychotherapies for PTSD. We investigated the degree to which educational achievement, often used as a proxy for intelligence, and estimated full scale intelligence quotient (FSIQ) scores themselves moderated treatment outcomes for two effective psychotherapies for PTSD: Cognitive Processing Therapy (CPT) and Written Exposure Therapy (WET). Participants, 126 treatment-seeking adults with PTSD (52% male; mean age = 43.9, SD = 14.6), were equally randomized to CPT and WET; PTSD symptom severity was measured at baseline and 6-, 12-, 24-, 36-, and 60-weeks following the first treatment session. Multilevel models revealed that participants with higher FSIQ scores experienced significantly greater PTSD symptom reduction through the 24-week assessment in CPT but not WET; this effect did not persist through the 60-week assessment. Educational achievement did not moderate symptom change through either 24- or 60-weeks. Individuals with higher FSIQ who are treated with CPT may experience greater symptom improvement in the early stages of recovery.

Behavioral activation (BA) is a well-supported treatment approach, but little research has been conducting on the effectiveness of this treatment within publicly-funded community mental health settings. We examined the feasibility of conducting a randomized trial examining the effectiveness of nine sessions of behavioral activation (BA) as a treatment for major depressive disorder (MDD) in a community mental health clinic (CMHC) setting. Following adaptation of a BA manual and training of BA therapists, 80 patients seeking treatment at a CMHC were randomized, with a 3:1 randomization rate of BA to nine sessions of treatment as usual (TAU). Feasibility assessments indicated that only one eligible patient refused randomization and that, of patients that attended at least one session, the median number of sessions was six for the BA group and eight for the TAU group. Of three post-baseline monthly assessments, 71.3% (171/240) were successfully obtained. On average, patients in the BA condition completed homework assignments 83.9% of the time. Treatment fidelity ratings indicated that substantially more BA techniques were delivered in the BA group compared to the TAU group (d=2.11). Measures of BA mechanisms improved significantly over time and these changes were significantly associated with change in depressive symptoms. These results indicate that it is feasible to conduct a randomized study of BA for MDD in a CMHC setting. In addition, the study reconfirmed the potential important of theory-relevant BA mechanism variables. Following these findings, further investigation into the effectiveness of BA in this setting is needed.

For many decades, the U.S. military's general operational guideline has been to limit the use of trauma-focused treatments for combat and operational stress reactions in military service members until they have returned from deployment. Recently, published clinical trials have documented that active-duty military personnel with combat-related posttraumatic stress disorder (PTSD) can be treated effectively in garrison. However, there are limited data on the treatment of combat and operational stress reactions or combat-related PTSD during military deployments. This prospective, nonrandomized trial evaluated the treatment of active-duty service members (N = 12) with combat and operational stress reactions or combat-related PTSD while deployed to Afghanistan or Iraq. Service members were treated by deployed military behavioral health providers using modified Prolonged Exposure (PE; n = 6) or modified Cognitive Processing Therapy (CPT; n = 6), with protocol modifications tailored to individual mission requirements. The PTSD Checklist-Military Version (PCL-M) total score was the primary outcome measure. Results indicated that both groups demonstrated clinically significant change in PTSD symptoms as indicated by a reduction of 10 points or greater on the PCL-M. Participants treated with modified PE had significant reductions in PTSD symptoms, t = -3.83, p = .01; g = -1.32, with a mean reduction of 18.17 points on the PCL-M. Participants treated with modified CPT had a mean PCL-M reduction of 10.00 points, but these reductions were not statistically significant, t = -1.49, p = .12; g = -0.51. These findings provide preliminary evidence that modified forms of PE and CPT can be implemented in deployed settings for the treatment of combat and operational stress reactions and combat-related PTSD.

Be a Mom is a self-guided web-based intervention, grounded in cognitive behavioral therapy, delivered to postpartum women to prevent persistent postpartum depression [PPD] symptoms. We aimed to evaluate Be a Mom in terms of its preliminary efficacy, feasibility, and acceptability. A pilot randomized, two-arm controlled trial was conducted. Eligible women (presenting PPD risk-factors and/or early-onset PPD symptoms) were enrolled in the study and were randomly assigned to the intervention (Be a Mom) or to the waiting-list control group. Participants in both groups completed baseline (T1) and postintervention (T2) assessments. The 194 women presenting risk factors/early-onset PPD symptoms were allocated to the intervention (n = 98) or to the control (n = 96) group. A significant Time × Group interaction effect was found for both depressive and anxiety symptoms, with women in the intervention group presenting a larger decrease in symptoms from T1 to T2 (p .05). Less than half of the women (41.8%) completed Be a Mom. Most women (71.4%) would use Be a Mom again if needed. Results provide preliminary evidence of the Be a Mom's efficacy, acceptability and feasibility, although further research is needed to establish Be a Mom as a selective/indicative preventive intervention for persistent PPD.

The goal of this study was to compare a brief behavioral treatment for insomnia (BBTI), which has fewer sessions (4), shorter duration (

Affective styles appear to be relevant to the development of psychopathology, especially anxiety disorders. The aim of the current study was to investigate changes in affective styles in patients with panic disorder and specific phobia, as a result of undergoing cognitive-behavioral therapy, and to identify a possible link between certain affective styles and remission. The sample consisted of outpatients (N = 101) suffering from panic disorder, specific phobia, or agoraphobia who completed the Affective Style Questionnaire (ASQ) before and after therapy, as well as at a 6-month follow-up assessment. Multivariate analyses of variance were conducted to test for changes due to therapy. Logistic regression analyses were calculated to test for the impact of affective styles on remission from anxiety disorders, and hierarchical regression analyses were calculated to examine the association between changes in affective styles and symptom reduction. Results indicated significant increases on the ASQ subscales adjusting and tolerating after therapy. Concealing did not decrease significantly after therapy. In addition, higher scores on adjusting significantly predicted remission from anxiety disorders. Finally, we found a significant association between increases on the adjusting scale and the reduction of anxiety symptoms.

Despite considerable data from randomized controlled trials supporting use of behavioral therapies for anxiety disorders and anxiety-related disorders, there is a relative scarcity of data demonstrating that such findings are generalizable to patients in nonresearch settings, and a lack of standardized repeated outcome measurement in such settings. Using one of the largest examinations of naturalistic outcomes of behavioral therapies in treatment-seeking patients (N = 489), we examined the clinical characteristics and treatment outcomes of patients seeking treatment for anxiety and anxiety-related disorders in the past 3 years. Patients seeking treatment at a clinic specializing in cognitive-behavioral therapy (CBT) completed self-report questionnaires via an electronic data capture system and diagnostic interview at baseline, and were reassessed at mid- and posttreatment. Patients with anxiety and related disorders were assessed for changes in symptom severity and secondary outcomes (impairment/functioning, quality of life, and depression) over the course of therapy. Patients showed clinically significant and statistically reliable improvement in anxiety symptom severity scores over treatment (p < .001), after controlling for number of sessions received. Patients also showed significant improvement in depression, quality of life, and functioning (p values ≤ .001). We also found significant improvement in disorder-specific symptoms, including obsessive-compulsive disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder (p values ≤ .001). Importance of, and ways to facilitate, integration of more routine assessment of a broader range of symptoms via online assessment systems and methods to better determine the effectiveness of CBT in naturalistic clinics are discussed.

Theories of cognitive therapy have long proposed that those with generalized anxiety disorder (GAD) have inaccurate expectations. By challenging them with objective evidence, symptoms are thought to decrease. To test these premises, this study used ecological momentary assessment (EMA) during the Worry Outcome Journal (WOJ) treatment to determine the percentage of GAD worries that did not come true. We then analyzed the association between participants’ untrue worry percentages and GAD symptom change across treatment. Twenty-nine participants with GAD recorded worries when prompted for 10 days, reviewed them online nightly, and tracked their worry outcomes across 30 days. These recordings were then coded by independent raters. Analyses applied bias-correct bootstrapping path analysis on slopes extracted from longitudinal linear mixed models. Primary results revealed that 91.4% of worry predictions did not come true. Higher percentages of untrue worries significantly predicted lower GAD symptoms after treatment, as well as a greater slope of symptom reduction from pre- to post-trial. Participants’ average expected likelihoods of worries coming true were much greater than actual observed likelihoods. The most common percentage of untrue worries per person was 100%. Thus, worries in those with GAD were mostly inaccurate. Greater evidence of this inaccuracy predicted greater improvement in treatment. As theorized, disconfirming false expectations may significantly contribute to treatment’s effect.

Body dysmorphic disorder (BDD) has a severe presentation and chronic course when untreated. Although effective BDD treatments exist, most individuals do not have access to them. We therefore developed and pilot tested the first smartphone-delivered individual cognitive-behavioral therapy (CBT) treatment for adults with BDD. The digital service was developed via user-centered design, integrating input from engineering, design, and psychology experts, plus BDD patient consultants. We conducted a 12-week open pilot trial (N = 10) to describe preliminary results for feasibility, acceptability, and treatment outcome. Attrition rates (0%) and feedback on usability and satisfaction indicated that smartphone-based CBT for BDD may be feasible, acceptable, and satisfactory. Initial results suggest that smartphone-based CBT for BDD may hold promise for improving BDD symptom severity, BDD-related insight, functional impairment, and quality of life, as scores from baseline to posttreatment improved with large-to-very large effects; depression improved with a medium effect. Ninety percent of participants were responders at posttreatment and 3-month follow-up. Smartphone-based CBT for BDD may have strong potential as a standardized, low cost, and accessible treatment for this debilitating illness. A test of efficacy is merited as a next step, using a well-powered, randomized control trial design.

Loneliness has been described as a common source of discomfort based on a subjective discrepancy between the actual and desired social situation. For some people this feeling may become a sustained state that is associated with a wide range of psychiatric and psychosocial problems. While there are few existing treatment protocols, interventions based on cognitive behavioral therapy (CBT) have shown positive effects. The current study investigated the efficacy of an 8-week internet-based treatment containing CBT components aimed at reducing feelings of loneliness. Seventy-three participants were recruited from the general public and randomly allocated to treatment or a wait-list control condition. Participants were assessed with standardized self-report measures of loneliness, depression, social anxiety, worry, and quality of life at pretreatment and posttreatment. Robust linear regression analysis of all randomized participants showed significant treatment effects on the primary outcome measure of loneliness (between group Cohen's d = 0.77), and on secondary outcomes measuring quality of life and social anxiety relative to control at postassessment. The results suggest the potential utility of internet-based CBT in alleviating loneliness but more research on the long-term effects and the mechanisms underlying the effects is needed.

Our field has come a long way in establishing cognitive-behavioral therapy as the empirically supported treatment of choice for a wide range of mental and behavioral health problems. Nevertheless, most individuals with mental disorders do not receive any care at all, and those who do often have difficulty accessing care that is consistently high in quality. Addressing these issues is complex and costly and thus progress has been slow. We are entering an exciting stage in which emerging technologies might offer novel solutions to the treatment gap. This paper discusses a number of technology-enabled solutions to our field's challenges, including Internet-based and smartphone-based cognitive-behavioral therapy. Nevertheless, we must remain attentive to potential pitfalls of these emerging technologies. The paper incorporates suggestions for how the field may approach these potential pitfalls and provides a vision for how we might develop powerful, scalable, precisely timed, personalized interventions to enhance global mental health.

The Cognitive Therapy Rating Scale (CTRS) is an observer-rated measure of cognitive behavioral therapy (CBT) treatment fidelity. Although widely used, the factor structure and psychometric properties of the CTRS are not well established. Evaluating the factorial validity of the CTRS may increase its utility for training and fidelity monitoring in clinical practice and research. The current study used multilevel exploratory factor analysis to examine the factor structure of the CTRS in a large sample of therapists (n = 413) and observations (n = 1,264) from community-based CBT training. Examination of model fit and factor loadings suggested that three within-therapist factors and one between-therapist factor provided adequate fit and the most parsimonious and interpretable factor structure. The three within-therapist factors included items related to (a) session structure, (b) CBT-specific skills and techniques, and (c) therapeutic relationship skills, although three items showed some evidence of cross-loading. All items showed moderate to high loadings on the single between-therapist factor. Results support continued use of the CTRS and suggest factors that may be a relevant focus for therapists, trainers, and researchers.

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40-50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9-14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At post-treatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at two-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to post-treatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders. This paper is currently in press in Behavior Therapy.

Anxiety and insomnia disorders are two of the most common and costly mental health conditions. They are frequently comorbid, but current treatments do not target both. To streamline treatment, we developed a computerized intervention targeting a transdiagnostic factor, safety aids (cognitive or behavioral strategies used to cope with distress that paradoxically exacerbate symptoms). We conducted a randomized controlled trial to determine the acceptability and efficacy of this brief one-session intervention. Young adult undergraduates (N = 61) with elevated subclinical anxiety and insomnia were randomized to receive the anxiety-insomnia intervention or a physical health control condition. Participants were followed for 1 month and completed self-report measures. Analyses indicated that participants found the intervention acceptable, credible, and engaging. Analyses revealed the active intervention reduced sleep- and anxiety-related safety aids, with medium to large effect sizes. Findings suggest that targeting safety aids for anxiety and insomnia is acceptable and effective in reducing the target mechanism, safety aids, as well as worry. Future research should replicate these findings within a clinical sample and with a longer-term follow-up.

Clinician fidelity to cognitive behavioral therapy (CBT) is an important mechanism by which desired clinical outcomes are achieved and is an indicator of care quality. Despite its importance, there are few fidelity measurement methods that are efficient and have demonstrated reliability and validity. Using a randomized trial design, we compared three methods of assessing CBT adherence-a core component of fidelity-to direct observation, the gold standard. Clinicians recruited from 27 community mental health agencies (n = 126; M age = 37.69 years, SD = 12.84; 75.7% female) were randomized 1:1:1 to one of three fidelity conditions: self-report (n = 41), chart-stimulated recall (semistructured interviews with the chart available; n = 42), or behavioral rehearsal (simulated role-plays; n = 43). All participating clinicians completed fidelity assessments for up to three sessions with three different clients that were recruited from clinicians' caseloads (n = 288; M age = 13.39 years SD = 3.89; 41.7% female); sessions were also audio-recorded and coded for comparison to determine the most accurate method. All fidelity measures had parallel scales that yielded an adherence maximum score (i.e., the highest-rated intervention in a session), a mean of techniques observed, and a count total of observed techniques. Results of three-level mixed effects regression models indicated that behavioral rehearsal produced comparable scores to observation for all adherence scores (all ps gt; .01), indicating no difference between behavioral rehearsal and observation. Self-report and chart-stimulated recall overestimated adherence compared to observation (ps lt; .01). Overall, findings suggested that behavioral rehearsal indexed CBT adherence comparably to direct observation, the gold-standard, in pediatric populations. Behavioral rehearsal may at times be able to replace the need for resource-intensive direct observation in implementation research and practice.

Recurrent, negative self-imagery is common in social anxiety disorder (SAD). Imagery rescripting (ImRs) is an effective therapeutic technique that aims to target past aversive memories to modify their associated meanings, and update the encapsulated negative schematic beliefs. The current study aimed to extend previous research by investigating the cognitive and affective shifts during each phase of ImRs delivered within a group cognitive behavioral therapy protocol. Participants (N = 32) retrieved an aversive memory associated with social anxiety and were guided through brief cognitive restructuring, prior to completing ImRs. Core beliefs associated with the memory (strength and valence) and fear of negative evaluation were assessed before and after ImRs and affect was assessed following each phase. Strength and affective valence of encapsulated core beliefs about the self, others, the world, and the image itself significantly reduced following ImRs, and core beliefs were updated to become more positive. Participants reported large affective shifts early in the process, with smaller shifts in the later stages. Fear of negative evaluation did not significantly reduce following ImRs. Outcomes provide some support for cognitive and affective changes during group ImRs for SAD and suggest future research directions to investigate longer-term impacts and to better understand the underlying mechanisms of the technique.

Cognitive Processing Therapy (CPT) is efficacious in treating PTSD, but there remains a need to improve outcomes for individuals who do not fully respond to treatment. Differences between patient-therapist dyads in the fidelity (i.e., adherence and competence) of CPT delivery and the quality of the therapeutic relationship may partly explain differential levels of symptom improvement. Sessions were sampled from a randomized trial comparing different consultation conditions in training therapists new to CPT. Among 69 patients, one session from Sessions 1-3 and one session from Sessions 4-7 were reliably rated for adherence and competence using the CPT Therapist Adherence and Competence Scale, and for therapeutic alliance using the Working Alliance Inventory-Observer scale. Mixed models, including detrending using a fixed effect of session, predicted self-reported Posttraumatic Stress Disorder Checklist (PCL-IV) scores in one session using process scores from the previous session. The statistical interaction between fidelity and alliance scores to predict outcome was also examined. Alliance had significant, positive correlations (rs = 0.18-0.21) with same-session adherence and competence. Higher competence scores and higher therapeutic alliance scores in one session were independently associated with lower PCL-IV scores in the subsequent session. Adherence scores, which tended to be very high with relatively less variability, did not significantly relate to subsequent-session PCL-IV scores. Competence significantly interacted with alliance, such that sessions high in both competence and alliance predicted especially lower subsequent-session PCL-IV scores. A strong therapeutic alliance may have a synergistic, salutary effect with the competent delivery of CPT.

Abstinence self-efficacy, coping skills, and therapeutic alliance are hypothesized mechanisms of behavioral change (MOBCs) in cognitive-behavioral therapy (CBT) for alcohol use disorder (AUD). However, little is known about when these hypothesized MOBCs change during treatment or in relation to the initiation of abstinence from alcohol, which the current study investigated. Patient-reported abstinence self-efficacy, drinking-related coping skills, and therapeutic alliance were measured at every session throughout a 12-session clinical trial that previously showed equivalent drinking reductions in female-specific individual- and group-based CBT for AUD. Participants (N = 121 women) were classified into subgroups based on whether and when they first initiated 14 days of continuous abstinence from alcohol during treatment. Interrupted time-series analyses evaluated the magnitude and timing of change in MOBC variables in relation to the initiation of abstinence. All three MOBC measures showed gradual improvements throughout treatment (within-subjects d = 0.03 to 0.09 change per week). Participants who initiated abstinence during treatment experienced additional sudden improvements in abstinence self-efficacy (d = 0.47) and coping skills (d = 0.27), but not therapeutic alliance (d = -0.02), the same week they initiated abstinence. Participants who were already abstinent when treatment started maintained higher abstinence self-efficacy and coping skills, but not therapeutic alliance, throughout treatment compared to participants who never initiated abstinence. Initiating abstinence may help facilitate improvements in abstinence self-efficacy and drinking-related coping skills. Clinicians may help patients anticipate when and how much these variables are expected to improve during treatment and encourage initiation of abstinence to potentially help facilitate improvements in abstinence self-efficacy and coping skills.

Social anxiety disorder (SAD) has been shown to be associated with difficulty in the ability to vicariously share others' positive emotions (positive affective empathy). Mixed evidence also suggests potentially impaired recognition of the positive and negative emotions of others (cognitive empathy) and impaired or enhanced sharing of the negative emotions of others (negative affective empathy). Therefore, we examined whether two efficacious treatments for SAD, cognitive-behavioral group therapy (CBGT) and mindfulness-based stress reduction (MBSR), improve empathy in SAD relative to a wait-list condition and whether improvements in empathy mediate improvements in social anxiety. In the context of a randomized controlled trial, participants with SAD completed an empathy task at baseline, posttreatment/wait-list (N = 81), and 1-year follow-up (N = 37). Relative to both MBSR and wait-list, CBGT resulted in significant improvements in positive affective empathy. CBGT-related changes in positive affective empathy also mediated improvements in social anxiety at both posttreatment/wait-list and at 1-year follow-up. Other indices of empathy did not change differentially across the three conditions. Therefore, one way in which CBGT may specifically confer benefits to individuals with SAD is through increasing their ability or willingness to share in the positive emotions of others.

Traditional cognitive-behavioral therapy (CBT) for anxiety disorders has been designed to target reductions in negative affect (NA) associated with defense-related processes. However, a subset of anxiety disorders, including social anxiety disorder (SAD), are also characterized by low positive affect (PA) resulting from separate deficits in appetitive-related processes. In contrast to CBT, "third-wave" approaches, such as acceptance and commitment therapy (ACT), align more consistently with motivational processes and, as a result, PA. However, the differential effect of CBT and ACT on PA and NA has yet to be investigated. Using secondary data from a randomized controlled trial, the present study sought to compare CBT's (n = 45) and ACT's (n = 35) effect on PA and NA in SAD. Findings were compared to a wait-list (WL) control condition (n = 31), as well as normative data from a general adult sample. Baseline PA and NA were also examined as moderators and predictors of theory-relevant treatment outcomes. NA decreased significantly in both CBT and ACT from pre to posttreatment. Although ACT outperformed WL in reducing NA, this effect was not observed for CBT. PA increased significantly in both CBT and ACT from pre to posttreatment, with neither ACT nor CBT outperforming WL in increasing PA. Neither PA nor NA were found to moderate theoretically relevant treatment outcomes. Findings suggest that ACT and CBT share common treatment mechanisms, making them more similar than distinct. Further efforts should be focused on optimizing CBT's and ACT's influence on threat and reward learning, and elucidating common processes of change.

The majority of people with depression in the United States either never seek treatment or gravitate exclusively to antidepressant medication (ADM), despite the existence of other effective treatments, such as cognitive-behavioral therapy (CBT). Reluctance to use psychotherapy is partly due to lack of appropriate mental health literacy and perceptions of low treatment acceptability (appropriateness for a given problem) and credibility (treatment logicalness, and whether the patient expects improvement). In the current investigation, we examined whether providing psychoeducation about CBT for depression would change participant perceptions of the treatment's acceptability and credibility. We recruited 554 (female n = 314; 57%) participants across two online studies, and assessed their baseline perceptions of CBT and ADM using modified Treatment Acceptability (TAAS) and Treatment Credibility and Expectancy (CEQ) scales. Participants were subsequently presented with evidence-based, expert-vetted psychoeducational materials describing CBT and ADM, and were asked to recomplete the TAAS and CEQ. In Study 1, participants endorsed significantly higher CBT-CEQ (credibility/expectancy) scores postpsychoeducation. In Study 2, participants endorsed significantly lower CBT-TAAS (acceptability), and among those with no exposure to depression treatments, endorsed significantly higher CBT-CEQ scores postpsychoeducation. In both studies, there were no perceptual changes of ADM after the psychoeducation. Finally, in Study 2, endorsement of a biological model of depression and depressive symptoms were negatively predictive of CBT's acceptability and credibility and expectancy postpsychoeducation. Perceptions of credibility and expectancy of CBT for depression appear malleable even after exposure to brief psychoeducation, whereas shifting perceptions of CBT's acceptability may require more extensive intervention.

Discrepancy between objective and subjective sleep parameters is a frequent symptom in persons suffering from insomnia. Since it has an impairing effect on daytime well-being and neglects possible positive objective improvements, it would be useful if it was treated. Apart from hypnotics, cognitive behavior therapy (CBT-I) is the therapy of choice for chronic forms of insomnia. However, there is limited information about whether CBT-I can also improve subjective-objective sleep discrepancy. We investigated a large sample of patients showing chronic forms of insomnia regarding their subjective-objective sleep discrepancy pre and post CBT-I. Objective sleep data were obtained from 3 nights (2 baseline nights and 1 night after therapy) using polysomnography in our sleep laboratory. All 92 patients participated in a 14-day inpatient program with CBT-I including psychoeducation about subjective-objective sleep discrepancy. Repeated measures analyses showed an improvement in subjective-objective sleep discrepancy parameters after CBT-I. Those parameters were also correlated with perceived quality of sleep. We conclude that CBT-I is a useful tool to improve subjective-objective sleep discrepancy in patients showing chronic forms of insomnia.

The evidence base for behavioral activation (BA) as a frontline treatment for depression is grounded in individual delivery. No valid previous meta-analytic reviews of BA delivered in groups have been conducted. This study therefore examined the efficacy and acceptability of group BA drawn from clinical trial evidence. Randomized controlled trials of group BA were identified using a comprehensive literature search. Depression outcomes at post-treatment/follow-up, recovery and drop-out rates were extracted and analyzed using a random-effects meta-analysis. Treatment moderators were analyzed using meta-regression and subgroup analyses. Nineteen trials were quantitatively synthesized. Depression outcomes post-group BA treatment were superior to controls (SMD 0.72, CI 0.34 to 1.10, k = 13, N = 461) and were equivalent to other active therapies (SMD 0.14, CI -0.18 to 0.46, k = 15, N = 526). Outcomes were maintained at follow-up for group BA and moderators of treatment outcome were limited. The drop-out rate for group BA (14%) was no different to other active treatments for depression (17%). Further research is required to refine the conditions for optimum delivery of group BA and define robust moderators and mediators of outcome. However, BA delivered in groups produces a moderate to large effect on depressive symptoms and should be considered an appropriate front-line treatment option.