Culture matters: Chinese mental health professionals' fear of losing face in routine outcome monitoring.

OBJECTIVE: The culturally salient fear of losing face might influence Chinese therapists' attitudes toward and use of routine outcome monitoring (ROM). We tested a model wherein self-face concern is associated with ROM use by way of attitudes toward ROM, and whether this process is weakened when therapists report high counseling self-efficacy and perspective-taking. METHOD: A national sample of Chinese mental health professionals (N = 371) completed questionnaires on their fear of losing face, attitudes toward ROM, ROM use, counseling self-efficacy, and perspective-taking. RESULTS: Regression-based analyses showed that fear of losing face was linked to greater negative attitudes toward ROM and lower ROM use. Greater negative attitudes mediated the relationship between fear of losing face and ROM use. However, neither counseling self-efficacy nor perspective-taking mitigated the relationship between self-face concern and ROM use; instead, they exacerbated this relationship through different paths. In the mediated pathway, counseling self-efficacy in coping with clients with difficult problems interacted with self-face concern to predict negative attitudes toward ROM. Perspective-taking served as a moderator that exacerbated the direct relationship between self-face concern and ROM use. CONCLUSIONS: Findings suggest the importance of considering culturally salient factors in implementing ROM in China and other non-Western contexts.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol.

BACKGROUND: The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings. METHODS/DESIGN: We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation. STATISTICAL ANALYSIS: Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention. DISCUSSION: This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

The Quality of Six Clinical Practice Guidelines in Health and Social Sciences: Are We on the Right Track?

Interest in the development and promotion of clinical practice guidelines (CPGs) continues to grow in many professions. However, the potential benefits associated with CPGs are dependent upon their quality. A number of studies have shown that the quality of CPGs varies greatly. Furthermore, the quality of many of the CPGs used in health and social sciences has yet to be examined. In light of this, the aim of this study was to examine the quality of CPGs that focus on intervention and care management in mental health in Quebec. A search of Quebec regulatory bodies websites was conducted and six CPGs were included in this study. The CPGs were assessed by four trained raters using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Items scores and domains scores were considered to determine the quality of the six CPGs. Results show that many of the CPGs did not achieve minimum ratings for numerous quality checks. Notably, none of the CPGs were designed using a rigorous methodology, they lacked transparency throughout the development process and insufficient consideration was given to the applicability of the recommendations they included. Because these shortcomings may hinder the efficacy and utilization of CPGs, suggestions to improve the development of CPGs and to improve their quality are discussed.

Can We Develop Evidence-Based Guidelines Without Research Expertise?

The development and implementation of clinical practice guidelines has flourished over the past two decades. Unfortunately, many studies have found that the quality of such guidelines is highly variable (Alonso-Coello et al. in Qual Safe Health Care 19:e58, 2010; MacQueen et al. in Can J Psychiatry 62:11-23, 2016); research suggests that some of the guidelines used in psychology have been developed using poor methods for guideline development (Bennett et al. in Depress Anxiety 35:330-340, 2018; Trepanier et al. in: Can Psychol 58: 211-217, 2017). While there remains a dearth of research in this area, typically, it is guidelines themselves that are examined by researchers, while too little attention is paid to the developers, and more specifically to how the guideline development groups are composed and the nature of the expertise of those involved in developing the guidelines. Given the importance of grounding guidelines in science, it is key that guideline development groups be comprised of research experts that will help ensure that this essential aspect be respected. In this brief paper, we provide findings from a recent study in which group composition as well as the expertise of guideline development committee members at the Order of Psychologists of Quebec (OPQ) was examined, as defined by academic research productivity. As results highlighted a clear imbalance between clinical and research expertise in these specific committees, with only a small percentage of researchers being represented, we conclude that major improvements need to be made for research to properly reach practitioners and make recommendations to facilitate this.

Short and long-term barriers and facilitators of skin self-examination among individuals diagnosed with melanoma.

BACKGROUND: Melanoma can be lethal if not detected early and treated. Early detection can be facilitated via skin self-examination (SSE) and as such, SSE is part of melanoma follow-up care for individuals with a prior history, who face a life-long risk of reoccurrence. The objective of the current study was to identify short- and long-term predictors of SSE among melanoma survivors to inform future prevention interventions in high-risk groups. METHOD: This is an observational study with longitudinal assessments conducted with adult melanoma patients in active follow-up care. PRIMARY OUTCOME MEASURES: Behavioral outcomes, comprehensive SSE (checking up to 5 body areas in the last 3 months) and optimal SSE (checking the entire body at least monthly in the last 3 months) were assessed at 3, 12, and 24 months post a dermatological educational session on skin cancer prevention. T tests and chi square analyses were used to examine changes in outcomes from 3 to 12 and 24 months. Linear and logistic regression models were used to examine the association between predictors and the primary outcomes. RESULTS: Comprehensive SSE did not decrease significantly from 3 (M = 2.7, SD = 1.1) to 12 (M = 2.6, SD = 1.2) and 24 months (M = 2.4, SD = 1.2) post the education session, with the stronger predictor at all timepoints being intentions to perform SSE. Optimal SSE was higher at 3 months (59%) compared to 12 (46%) and 24 months (34%), with key predictors including self-efficacy and intentions to perform SSE and male sex at 3 months post; self-efficacy and reliance on medical advice at 12 months; and (lower) education and self-efficacy at 24 months. CONCLUSIONS: The key findings of this study are that 1) survivors maintain SSE behaviour over time, but rates of SSE performed in agreement with medical recommendations are higher immediately post standard dermatological education (i.e. usual care) and decrease somewhat over a 24-month period; and 2) the strongest psycho-social predictors of SSE are intentions and self-efficacy to perform the behavior, which are highly modifiable, for example via motivational interviewing and goal setting health interventions.

Changes in depressed patients' self-statements.

Objective: Individuals' use of self-statements reflecting self-criticism, a sense of inadequacy, and low self-worth has been linked to the incidence, severity, and recurrence of major depressive disorder [de Graaf, L. E., Huibers, M. J. H., Cuijpers, P., & Arntz, A. (2010). Minor and major depression in the general population: Does dysfunctional thinking play a role? Comprehensive Psychiatry, 51(3), 266-274. doi:10.1016/j.comppsych.2009.08.006; Riso, L. P., du Toit, P. L., Blandino, J. A., Penna, S., Dacey, S., Duin, J. S., … Ulmer, C. S. (2003). Cognitive aspects of chronic depression. Journal of Abnormal Psychology, 112(1), 72-80. doi:10.1037/0021-843X.112.1.72]. The present study used an observer-rated measure, the Structural Analysis of Social Behavior [Benjamin, L. S. (1974). Structural Analysis of Social Behavior. Psychological Review, 81(5), 392-425. doi:10.1037/h0037024], to examine patients' self-directed communication over the course of psychotherapy.Method: Self-talk in early and late therapy sessions was examined using cases (N = 44) from the cognitive therapy arm of Jacobson and colleagues' component study of cognitive therapy for depression [Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., … Prince, S. E. (1996). A component analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295-304. doi:10.1037/0022-006x.64.2.295, Jacobson, N. S., Dobson, K. S., Truax, P. A., Addis, M. E., Koerner, K., Gollan, J. K., … Prince, S. E. (2000). A component analysis of cognitive-behavioral treatment for depression. Prevention & Treatment, 3(1). doi:10.1037/1522-3736.3.1.323a]. We identified changes at treatment termination, and used hierarchical multiple regression to examine whether improvements in patient self-talk influenced treatment outcome up to 24 months post-termination.Results: Trends indicate that patients used friendlier and less critical self-statements at the end of treatment. Decreased self-critical behaviour was associated with fewer symptoms at the end of treatment and up to one year later; increased self-acceptance was linked to symptom improvement a year and a half after termination.Conclusion: Consistent with cognitive theory, reduced self-criticism was associated with better treatment outcomes. Longer-term improvement was linked to the development of friendlier and more accepting self-referential behaviour.

Decarboxylative ipso Amination of Activated Benzoic Acids.

In the presence of a bimetallic Pd/Cu system with 1,10-phenanthroline as the ligand and either air or N-methylmorpholine N-oxide as the oxidant, electron-deficient benzoic acids undergo oxidative decarboxylative coupling with unprotected amines. This operationally simple aniline synthesis is widely applicable with respect to the amine and gives good yields, even on multigram scale. The orthogonality of this reaction to other Pd-catalyzed cross-couplings allows the concise synthesis of multisubstituted arenes by sequential C-C, C-Cl, and C-N functionalizations. Mechanistic investigations suggest the intermediacy of a hypervalent Pd species.

Transition-Metal-Free Synthesis of Biarylmethanes from Aryl Iodides and Benzylic Ketones.

An original metal-free procedure for the synthesis of biarylmethanes is disclosed herein. The reactions occur with high selectivity starting from aryl iodides and benzylic ketones in the presence of superbasic media (CsOH/DMSO). This procedure allows a straightforward access to a wide range of biarylmethane derivatives substituted with electron-withdrawing and -donating substituents.

Regiospecific ortho-C-H Allylation of Benzoic Acids.

A carboxylate-directed ortho-C-H functionalization has been developed and it allows the regiospecific introduction of allyl residues to benzoic acids. In the presence of a [Ru(p-cymene)Cl2 ]2 and K3 PO4 , benzoic acids react with allyl acetates at only 50 °C to give the corresponding ortho-allylbenzoic acids. The protocol is generally applicable to both electron-rich and electron-poor benzoic acids in combination with linear and branched allyl acetates. The products can be further functionalized in situ, for example, by double-bond migration, lactonization, or decarboxylation.

Carboxylic Acids as Directing Groups for C-H Bond Functionalization.

The selective transformation of C-H bonds is one of the most desirable approaches to creating complexity from simple building blocks. Several directing groups are efficient in controlling the regioselectivity of catalytic C-H bond functionalizations. Among them, carboxylic acids are particularly advantageous, since they are widely available in great structural diversity and at low cost. The carboxylate directing groups can be tracelessly cleaved or may serve as the anchor point for further functionalization through decarboxylative couplings. This Minireview summarizes the substantial progress made in the last few years in the development of reactions in which carboxylate groups direct C-H bond functionalizations with formation of C-C, C-O, C-N, or C-halogen bonds at specific positions. It is divided into sections on C-C, C-O, C-N, and C-halogen bond formation, each of which is subdivided by reactions and product classes. Particular emphasis is placed on methods that enable multiple derivatizations by combining carboxylate-directed C-H functionalization with decarboxylative couplings.

The Relationship between Depression Severity and Cognitive Errors.

Cognitive errors (CEs) are evidenced to be related to depressive thinking in major depressive disorder (Beck Et Al., 1979; Dozois & Beck, 2008). Studies using self-report questionnaires demonstrate that CEs are more prevalent in individuals with depression than in non-depressed individuals (Gupta & Kar, 2008) and that CEs are related to depression severity (Miranda & Mennin, 2007). The study discussed in this paper aimed to describe CEs in depressed patients and examined the relationship between CEs and severity of depression. Participants (N = 45) undergoing cognitive therapy were assessed for CEs and for depression at session three using the Cognitive Errors Rating System (CERS; Drapeau et al., 2008) and the Beck Depression Inventory (BDI; Beck et al., 1979). Participants had more negative CEs than positive, and the most prevalent cluster of CEs was selective abstraction. Participants deemed as being "high distorters" on the CERS had significantly more negative CEs, but not positive CEs, than "low distorters" despite not differing on BDI scores. Psychotherapy research and practice implications are discussed.

An Empirical Investigation of Defense Interpretation Depth, Defensive Functioning, and Alliance Strength in Psychodynamic Psychotherapy.

The present study examined the relationship between depth of defense interpretations by therapists, and patient defensive functioning, on the therapeutic alliance in a sample of 36 patients undergoing short-term dynamic psychotherapy. Defense interpretation depth was defined as the degree to which therapist interpretations contained information regarding the motivation for patient defenses and historical origins of the defensive processes (Greensen, 1967). Mean depth of interpretation was compared between sessions that were identified beforehand as either high-alliance or low-alliance sessions using the Helping Alliance Questionnaire (HAq-II: Luborsky et al., 1996). Results indicated that defensive functioning was correlated to defense interpretation depth in low-alliance sessions. Moreover, mean depth of interpretation was also higher in low-alliance sessions, pointing to the possible "destabilizing" effects that these interpretations may have on both defensive functioning and the therapeutic alliance. These results are discussed within the context of previous studies of therapeutic technique in dynamic psychotherapy.

[Effectiveness of psychotherapy compared to pharmacotherapy for the treatment of anxiety and depressive disorders in adults: A literature review]. / Efficacité de la psychothérapie comparativement à la pharmacothérapie dans le traitement des troubles anxieux et dépressifs chez l'adulte : une revue de la littérature.

Introduction In Quebec, mental disorders affect one in five people in their lifetime. Anxiety and depressive disorders are the main common or moderate mental health disorders. They affect both the individuals with the disorder and the people around them and have substantial economic impact. Psychotropic drugs are the treatment option most often proposed to patients presenting with moderate mental health disorders. Psychotherapy is nevertheless a treatment that should be given consideration.Physical and financial access to psychotherapy remains limited because only one third of professionals qualified to offer it practise in the public sector, and the coverage and reimbursement policy for this service is very restricted. In order to improve such coverage, the Ministère de la Santé et des Services sociaux (MSSS) mandated the Institut national d'excellence en santé et en services sociaux (INESSS) to assess the evidence on the effectiveness of psychotherapy compared with those of pharmacotherapy for the treatment of adults with anxiety and depressive disorders.Methods An update of a review of recent and good quality literature was conducted through a review of systematic reviews dealing with psychotherapy compared to pharmacotherapy in the treatment of anxiety and depression in adults. The period covered included 2009 to 2013. The literature search strategy, modelled on that of the reference review, was applied to Medline, Cochrane Library, CINAHL, Web of Science and health technology assessment agencies. Exploration of the grey literature focused on information available on the websites of various health assessment organizations.Results The level of scientific evidence overall was judged to be of moderate to high quality. In general, the data showed no significant difference between psychotherapy and pharmacotherapy in terms of symptoms reduction in patients with moderate anxiety or depressive disorders, indicating comparable effectiveness of these two modes of treatment. However, the benefits of psychotherapy lasted longer after the end of treatment than those of medication. Psychotherapy therefore offers better protection against relapse. Furthermore, the combination of psychotherapy and pharmacotherapy is more effective than psychotherapy alone in severe or chronic cases.Conclusion Psychotherapy appears to be as effective as pharmacotherapy in the treatment of adult patients with moderate anxiety and/or depressive disorders. Moreover, the beneficial effects of psychotherapy last longer after the end of treatment with a lower likelihood of relapse.

[Access to government-funded psychotherapy: Comparing the point of view of psychologists and psychotherapists]. / Accessibilité à la psychothérapie subventionnée par l'État : comparaisons entre les perspectives des psychologues et des psychothérapeutes.

Objectives Within the Quebec context, as well as the larger Canadian and International context, increasing access to mental health care treatment has become a major health care priority (see Peachey, Hicks, & Adams, 2013). Initiatives to increase access through government-funded psychotherapy have been successfully implemented in Australia and the United Kingdom. The current study sought to document how licensed psychologists and psychotherapists in Quebec differ in their attitudes about the components of these government-funded psychotherapy programs and increasing access to psychotherapy treatment.Methods The target population for the study included both psychologists and psychotherapists whom were licensed to practice psychotherapy with the Ordre of Psychologists of Quebec. Participants (N = 1 275) were recruited by email to participate in an online questionnaire focusing on components such as the services that should be offered in a new government-funded psychotherapy model (eg., individual therapy, family therapy; including employment and debt counselling), the choice and autonomy clinicians have in their treatment interventions, the role of the referring General Practitioner (GP), the fees per psychotherapy hour, the hiring structure (e.g., in the public sector versus reimbursing private psychotherapy services), among others.Results The results indicated that psychotherapists were more in favour of including family and couple therapy, and employment/vocational counselling than psychologists. Psychologists were more in favour of using evidence-based practices as well as tracking treatment outcomes using validated measures, and publishing treatment satisfaction ratings to the public. Psychotherapists were more in favour of being paid on a session-to-session basis as opposed to be being hired on a salaried basis to offer government-funded psychotherapy.Conclusions Given that psychologists and psychotherapists differ in their training background and have historically played different roles in the health care system, it is important to understand how they differ in their perspectives on accessibility to psychotherapy. The implications for implementing government-funded psychotherapy initiatives in Quebec given the different professional perspectives of the two groups are discussed.

Transition-Metal-Free α-Arylation of Enolizable Aryl Ketones and Mechanistic Evidence for a Radical Process.

The α-arylation of enolizable aryl ketones can be carried out with aryl halides under transition-metal-free conditions using KOtBu in DMF. The α-aryl ketones thus obtained can be used for step- and cost-economic syntheses of fused heterocycles and Tamoxifen. Mechanistic studies demonstrate the synergetic role of base and solvent for the initiation of the radical process.

On the frontier between nucleophilic aromatic substitution and catalysis.

A study on the arylation of heteroatom nucleophiles by using activated haloarenes, with or without metal catalysts, is reported. A discussion concerning the involvement of traces of metals is presented, supported by an unexpected ''ligand'' effect in the absence of added metal catalysts. We believe that the frontier between nucleophilic aromatic substitution and catalysis will likely prove to be much harder to delimit than is generally thought.

The assessment of cognitive errors using an observer-rated method.

OBJECTIVE: Cognitive Errors (CEs) are a key construct in cognitive behavioral therapy (CBT). Integral to CBT is that individuals with depression process information in an overly negative or biased way, and that this bias is reflected in specific depressotypic CEs which are distinct from normal information processing. Despite the importance of this construct in CBT theory, practice, and research, few methods are available to researchers and clinicians to reliably identify CEs as they occur. METHOD: In this paper, the author presents a rating system, the Cognitive Error Rating Scale, which can be used by trained observers to identify and assess the cognitive errors of patients or research participants in vivo, i.e., as they are used or reported by the patients or participants. CONCLUSIONS: The method is described, including some of the more important rating conventions to be considered when using the method. This paper also describes the 15 cognitive errors assessed, and the different summary scores, including valence of the CEs, that can be derived from the method.

Finding a needle in a haystack: The identification of clinical practice guidelines for psychosocial oncology through an environmental scan of the academic and gray literature.

OBJECTIVE: Clinical practice guidelines (CPGs) are evidence-based tools well-suited to translate the latest research evidence into recommendations for routine clinical care. Given the rapid expansion of psychosocial oncology research, they represent a key opportunity for informing the treatment decisions of overburdened clinicians, standardizing service delivery, and improving patient-reported outcomes. Yet, there is little consensus on how clinicians can most effectively access these tools and little to no information on the current availability and scope of CPGs for the range of psychosocial symptoms and concerns experienced by patients with cancer. METHOD: Our environmental scan consisted of an academic and gray literature designed to identify currently available CPGs addressing a range of cancer-related psychosocial symptoms. RESULTS: Findings revealed a total of 23 existing psychosocial oncology CPGs that met full eligibility criteria. The gray literature search was found to be more effective at identifying CPGs (n = 22) compared to the academic search (n = 9). CONCLUSION: Several concerns arose from the systematic search. The limited publication of CPGs in peer-reviewed journals may make clinicians and stakeholders more hesitant to implement CPGs due to uncertainties about the methodological rigor of the development process. Further, many existing CPGs are outdated or failed to be updated according to guideline recommendations, meaning that the recommendations may fall short of their purpose to translate up-to-date research findings. FUTURE DIRECTIONS: Future research should seek to systematically assess the quality of existing psychosocial oncology CPGs and shed light on the current state of implementation and adherence in clinical practice in order to better inform guideline developers on the current needs of the psychosocial oncology community.

Barriers and facilitators of adherence to medical advice on skin self-examination during melanoma follow-up care.

BACKGROUND: Melanoma is the fastest growing tumor of the skin, which disproportionately affects younger and middle-aged adults. As melanomas are visible, recognizable, and highly curable while in early stages, early diagnosis is one of the most effective measures to decrease melanoma-related mortality. Skin self-examination results in earlier detection and removal of the melanoma. Due to the elevated risk of survivors for developing subsequent melanomas, monthly self-exams are strongly recommended as part of follow-up care. Yet, only a minority of high-risk individuals practices systematic and regular self-exams. This can be improved through patient education. However, dermatological education is effective only in about 50% of the cases and little is known about those who do not respond. In the current literature, psychosocial variables like distress, coping with cancer, as well as partner and physician support are widely neglected in relation to the practice of skin self-examination, despite the fact that they have been shown to be essential for other health behaviors and for adherence to medical advice. Moreover, the current body of knowledge is compromised by the inconsistent conceptualization of SSE. The main objective of the current project is to examine psychosocial predictors of skin self-examination using on a rigorous and clinically sound methodology. METHODS/DESIGN: The longitudinal, mixed-method study examines key psychosocial variables related to the acquisition and to the long-term maintenance of skin self-examination in 200 patients with melanoma. Practice of self-exam behaviors is assessed at 3 and 12 months after receiving an educational intervention designed based on best-practice standards. Examined predictors of skin self-exam behaviors include biological sex, perceived self-exam efficacy, distress, partner and physician support, and coping strategies. Qualitative analyses of semi-structured interviews will complement and enlighten the quantitative findings. DISCUSSION: The identification of short and long-term predictors of skin self-examination and an increased understanding of barriers will allow health care professionals to better address patient difficulties in adhering to this life-saving health behavior. Furthermore, the findings will enable the development and evaluation of evidence-based, comprehensive intervention strategies. Ultimately, these findings could impact a wide range of outreach programs and secondary prevention initiatives for other populations with increased melanoma risk.

Change in cognitive errors and coping over the course of brief psychodynamic intervention.

OBJECTIVE: Cognitive change over the course of psychodynamic psychotherapy has been postulated by several models, but has rarely been studied. Based on the adaptive skills model (Badgio, Halperin, & Barber, 1999), it is reasonable to expect that very brief dynamic psychotherapy may be associated with change in coping patterns and cognitive errors (also known as cognitive distortions) y. METHOD: N = 50 outpatients presenting with various psychiatric disorders and undergoing 4 sessions of Brief Psychodynamic Intervention (BPI; Despland, Drapeau, & de Roten, 2005; Despland, Michel, & de Roten, 2010) were included in this naturalistic study (mean age: 31 years; 56% female; all Caucasian). Cognitive errors and coping strategies were assessed using the Cognitive Errors Rating Scale (Drapeau et al., 2008) and Coping Patterns Rating Scale (Perry et al., 2005). These observer rated methods were applied to the verbatim transcriptions of all 4 therapy sessions completed by each patient. RESULTS: Results indicate change in both cognitive errors and coping patterns over the course of BPI, including an increase in the Overall Coping Functioning and a decrease in unhelpful coping processes, such as isolation, which reflects a shift in participant appraisal towards stress appraised as a challenge at the end of treatment. These changes predicted symptom change at the end of treatment. While cognitive errors also changed over the course of BPI, no predictive effect was found with regard to symptom change. CONCLUSIONS: These results are interpreted within the framework of common change principles in psychotherapy. Implications and future research are discussed.