A Qualitative Study Into the Relative Stigmatization of Mental Illness by Mental Health Professionals.

Mental health professionals stigmatize mental illness, which has significant ramifications for public health and policy. Within this domain, there is a lack of comprehensive research on relative stigma, emotions, and behaviors and an absence of literature that can guide research on these topics. The current study sought to address these limitations. Unstructured interviews were conducted with 22 mental health professionals, and data were analyzed using a grounded theory approach. The current study identified a collection of mental disorders (e.g., borderline personality disorder), stereotypes (e.g., dangerousness), emotion-related responses (e.g., fear), and behaviors (e.g., helping) as being key to the relative stigmatization of mental illness by mental health professionals. The results also suggested that professional context and familiarity with mental illness decrease the stigmatization of mental illness by mental health professionals. These variables and constructs were combined to form a grounded theory of mental health professionals stigmatizing mental illness. The current study has implications for the direction of future research on the stigmatization of mental illness by mental health professionals and interventions that strive to mitigate this type of stigmatization.

Impairments in Physiological Reactivity to Emotive Stimuli After Traumatic Brain Injury: A Systematic Review of Skin Conductance and Heart Rate Variability Evidence.

OBJECTIVE: To examine evidence of impairments in physiological reactivity to emotive stimuli following traumatic brain injury (TBI). METHODS: A search of PsychINFO, CINAHL (Cumulative Index to Allied Health Literature), Web of Science, EMBASE (Excerpta Medica dataBASE), and Scopus databases was conducted from 1991 to June 24, 2021, for studies comparing changes in skin conductance or heart rate variability to emotive stimuli between adults with TBI and controls. Two reviewers independently assessed eligibility and rated methodological quality. RESULTS: Twelve eligible studies examined physiological reactivity to laboratory-based emotive stimuli, which included nonpersonal pictures/videos, posed emotion, stressful events, and personal event recall. Overall, 9 reported evidence that individuals with TBI experience lower physiological reactivity to emotive stimuli compared with healthy controls, although the findings varied according to the type and valence of emotional stimuli and physiological parameter. Most studies using nonpersonal pictures or videos found evidence of lower physiological reactivity in TBI participants compared with controls. CONCLUSIONS: Based on laboratory-based studies, individuals with TBI may experience lower physiological reactivity to emotive stimuli. Further research is needed to investigate physiological responses to personally relevant emotional stimuli in real-world settings and to understand the interplay between physiological reactivity, subjective experiences, and behavior.

Telehealth use by mental health professionals during COVID-19.

OBJECTIVE: To examine and describe telehealth use and attitudes among mental health professionals in Australia and New Zealand during the initial stages of the COVID-19 pandemic. METHODS: Participants completed a brief online survey between May and July 2020. Participants were recruited via peak and professional organisations and through psychology-focused social media groups and networks. The survey examined frequency of telehealth use, reasons for non-use, telehealth modalities, prior use, attitudes towards use, plans for future use, and training, information or resource needs. RESULTS: A total of 528 professionals (85.2% female) participated in the survey, of which 98.9% reported using telehealth and 32.2% reported using telehealth exclusively. Respondents were less likely to use telehealth if they worked with clients experiencing complex issues (e.g. trauma), had more hours of weekly client contact, had a choice about whether to use telehealth or felt less positive about using technology. Respondents were more likely to hold positive views towards telehealth if they were female, had used online programmes with clients previously, were frequent telehealth users and were comfortable using technology. Participants expressed mixed views on client safety and the impact of telehealth on therapeutic process and effectiveness. CONCLUSION: Telehealth has a clear and ongoing role within mental healthcare and there is a need for strong guidance for professionals on how to manage client risk, privacy, security and adapt therapy for delivery via telehealth. In particular, there is a need for individual-, organisational-, professional- and policy-level responses to ensure that telehealth remains a viable and effective healthcare medium into the future.

Understanding client engagement in digital mental health interventions: An investigation of the eTherapy Attitudes and Process Questionnaire.

AIMS: Digital mental health services may increase the accessibility and affordability of mental health treatments. However, client dropout a low use is often reported. The purpose of the current study was to investigate the structural validity of the e-Therapy Attitudes and Process (eTAP) questionnaire, as a theoretically based (theory of planned behavior) tool for understanding ongoing client engagement intentions with digital mental health treatments. The possible role of eHealth literacy in predicting behavioral intentions to use digital mental health treatments was also examined. METHODS: Participants were 244 Australian-based adults aged between 18 and 56 years, who were currently using a digital mental health tool. Data were collected via online survey. RESULTS: Confirmatory Factor Analysis was conducted, with good model fit obtained following two theoretically supported modifications. Moderated hierarchical regression supported the utility of the theory of planned behavior in predicting behavioral intentions, with attitudes emerging as a strong and consistent individual predictor. No support was found for the moderating role or individual significance of eHealth literacy. CONCLUSIONS: These findings support the clinical and research use of the eTAP as a theory-based measure to understand client engagement in digital mental health interventions. The study also highlights the need for interventions to target attitudes to improve clients' ongoing engagement in digital mental health.

Organizational and Policy Barriers to the Use of Digital Mental Health by Mental Health Professionals.

Background: Digital mental health (DMH) provides effective methods of overcoming issues of time constraints, accessibility, and availability of mental health care. They can provide a valuable means to deliver mental health care in the present pandemic. However, adoption of these methods has been slow. Mental health professional (MHP) concerns at the organizational and policy level that influence this slow adoption need to be examined. Materials and Methods: A narrative review was conducted to identify the barriers. Searches using the databases Scopus, Embase, and PubMed were conducted to identify research focused on barriers reported by MHPs to use DMH. Results: The search resulted in 356 unique citations, and 21 papers met the inclusion and exclusion criteria. Forward and backward sampling resulted in identifying an additional 19 relevant papers. Discussion: Unmet needs for information, training, and infrastructure, challenges to the workflow and excessive workloads, and ambiguous policies serve as barriers to DMH use. This article recommends strategies for researchers, organizations, DMH designers, and governmental institutions to ensure efficient utilization of DMH. Conclusions: Concerted efforts at individual, organizational, and governmental levels are essential to ensure efficient utilization of DMH.

Development of a measure of stigma towards occupational stress for mental health professionals.

PURPOSE: Stigma is a common barrier to mental health professionals (MHPs) seeking help for occupational stress and burnout, although there is a lack of psychometrically sound tools to measure this construct. The current study aimed to develop and validate a scale (the Mental Health Professional Stigma Scale; MHPSS) for this purpose. METHODS: The MHPSS and related measures were completed by 221 Australian MHPs via online survey, with a subsample completing the MHPSS again 2 weeks after initial completion. RESULTS: Exploratory factor analysis revealed a four-factor solution, comprising of 13 items and accounting for 50.16% of variance. Factors were Perceived Other Stigma, Perceived Structural Stigma, Personal Stigma, and Self stigma. The internal consistency, test-retest reliability, and validity of the scale were supported. CONCLUSIONS: The MHPSS has utility to capture stigmatising attitudes and beliefs related to occupational stress and burnout among MHPs. It may be used to assist in the development and evaluation of initiatives to reduce stigma and increase help-seeking among MHPs.

Stressors and protective factors among regional and metropolitan Australian medical doctors: A mixed methods investigation.

OBJECTIVE: This study aimed to compare stress, burnout, stressors, and protective factors among regional- and metropolitan-based Australian medical doctors. METHOD: A mixed methods design was utilized with 252 Australian medical doctors completing an online questionnaire package. A subsample also completed qualitative interviews. RESULTS: Stress was significantly higher among doctors compared with population norms. Over half of doctors reported burnout on one or more dimensions. The strongest unique predictors were being female, working late, and work-family conflict. Qualitatively, 12 stressors (e.g., training and competition, workload, and time management) and 9 protective subthemes (e.g., being well resourced, clinical interest) emerged across system-level, clinical environment-level, and individual factor and personal response themes. CONCLUSIONS: Stress and burnout among doctors are alarmingly high and both system/organization-level (e.g., communication systems, workload, flexible work arrangements) and individual-level (e.g., fostering resilience/coping strategies) predictors are implicated by our results. These may be useful targets for future interventions.

Exploring scale validity and measurement invariance of the Toronto Mindfulness Scale across levels of meditation experience and proficiency.

OBJECTIVES: The Toronto Mindfulness Scale (TMS) is a widely used instrument of state mindfulness. Research suggests the interpretation and functioning of mindfulness scale items may differ as a function of meditation experience, and thus, establishing invariance across experience levels is essential. METHODS: Five hundred and five meditation practitioners (32.7% male, 33.3% female, and 34.1% unspecified) with an average age of 42.37 years (SD = 12.70) completed the TMS online. RESULTS: Results support at least partial invariance across subgroups based on years of mindfulness meditation experience and self-reported proficiency. Construct validity of the Decentering subscale was also supported; however, the Curiosity subscale did not meet validity expectations, as it required additional model modifications to yield good fit, and means were not sensitive to differences in group experience or proficiency. CONCLUSIONS: Our findings suggest further review of the TMS Curiosity items may be warranted to determine its suitability for use within mindfulness assessment.

What prevents doctors from seeking help for stress and burnout? A mixed-methods investigation among metropolitan and regional-based australian doctors.

OBJECTIVE: Despite the increased risk of experiencing mental health concerns, particularly related to stress and burnout, psychological help-seeking among medical doctors is typically low. This study examined the barriers to treatment experienced by doctors for stress and burnout-related difficulties. METHODS: A mixed-methods design was adopted. The quantitative sample comprised 274 Australian-based medical doctors. Qualitative interviews were conducted with a subsample of 20 (11 regional and 9 metropolitans) doctors. For triangulation, five stakeholder interviews were also conducted with representatives of the profession. RESULTS: Time was the greatest barrier to treatment. Qualitatively, doctors identified barriers such as stigma and fear of professional consequences, and particularly among regional doctors, access to services and professional culture. CONCLUSIONS: There is a need for tailored strategies to address barriers to psychological treatment among doctors for improving service access and mental health.

Not quite city and not quite rural: Active lifestyle beliefs in peri-urban Australians.

ISSUE ADDRESSED: Residents of peri-urban Australia face health inequalities compared to city dwellers. Active lifestyles provide many benefits that could improve the health of this population; however, peri-urban Australians are more likely to be inactive and sedentary. The aim of this study was to identify the physical activity and sedentary behaviour-related beliefs of peri-urban Australians. METHODS: Semi-structured interviews were undertaken with adult residents of peri-urban, southern Queensland. Participants (N = 8) were recruited from a related study, purposefully selected to ensure diversity. Data were analysed by thematic analysis. Interviews were conducted until data and inductive-thematic saturation were reached. RESULTS: Three themes were identified, representing beliefs about intrapersonal, interpersonal/socio-cultural and physical environmental factors relevant to active lifestyles among peri-urban Australians. Active lifestyle behaviours were perceived as beneficial for health. Social interaction was described as an important outcome of physical activity. Features of the physical environment negatively impacted the perceived difficulty of performing physical activity and avoiding sedentary behaviour. CONCLUSIONS: Active lifestyle strategies that support social interaction through physical activity and participation in sports may be particularly useful in peri-urban environments where opportunities for social interaction are limited. Such strategies should also take into account contextual factors that negatively impact active lifestyle control beliefs (eg, distance). SO WHAT?: This study provides insight into factors that may influence the active lifestyles of peri-urban Australians. This information can be used to develop contextually relevant strategies designed to encourage physical activity, discourage sedentary behaviour and assist to relieve health disparities faced by this population.

Development of the SOSS-D: a scale to measure stigma of occupational stress and burnout in medical doctors.

BACKGROUND: Occupational stress and burnout are highly prevalent among doctors, with stigma identified as a barrier to help-seeking in this population. However, there has been a lack of a standardised tool to measure stigma of occupational stress and burnout among doctors. AIMS: The aim of the current study was to develop and investigate the psychometric properties of the Stigma of Occupational Stress Scale for Doctors (SOSS-D). METHOD: An online questionnaire package was completed by 200 (38 male, 162 female) doctors. Participants completed measures relating to help-seeking intentions, general stigma, and the SOSS-D. RESULTS: Exploratory Factor Analysis was used to refine the scale to an 11-item version. The analysis revealed a three-factor structure, which explained 63.4% of variance. Factors related to perceived structural stigma, personal stigma and perceived other stigma. The internal consistency, convergent, discriminant and criterion validity of the scale were supported. CONCLUSIONS: The SOSS-D may assist educators and mental health professionals in measuring and assessing the efficacy of interventions designed to reduce stigma. As such, it is anticipated that the SOSS-D will be a useful instrument for understanding and addressing stigma of occupational stress and burnout among medical doctors, to improve help-seeking behaviours in this population.

Going global: do consumer preferences, attitudes, and barriers to using e-mental health services differ across countries?

BACKGROUND: e-Mental health services have the capacity to overcome barriers to care and reduce the unmet need for psychological services, particularly in developing countries. However, it is unknown how acceptable e-mental health interventions may be to these populations. AIMS: The purpose of the current study was to examine consumer attitudes and perceived barriers to e-mental health usage across four countries: Australia, Iran, the Philippines and South Africa. METHODS: An online survey was completed by 524 adults living in these countries, assessing previous contact with e-mental health services, willingness to use e-mental health services, and perceived barriers and needs for accessing e-mental health services. RESULTS: Although previous contact with e-mental health services was low, the majority of respondents in each sample reported a willingness to try e-mental health services if offered. Barriers toward e-mental health usage were higher among the developing countries than Australia. The most commonly endorsed barriers concerned needing information and assurances regarding the programmes. CONCLUSIONS: Across countries, participants indicated a willingness to use e-mental health programmes if offered. With appropriate research and careful implementation, e-mental health has the potential to be a valuable part of mental healthcare in developing countries.

A randomized controlled trial of mindfulness to reduce stress and burnout among intern medical practitioners.

INTRODUCTION: Stress and burnout are highly prevalent among medical doctors, and are associated with negative consequences for doctors, patients, and organizations. The purpose of the current study was to examine the effectiveness of a mindfulness training intervention in reducing stress and burnout among medical practitioners, by means of a Randomised Controlled Trial design. METHODS: Participants were 44 intern doctors completing an emergency department rotation in a major Australian hospital. Participants were randomly assigned to either an active control (one hour extra break per week) or the 10-week mindfulness training intervention. Measures of stress and burnout were taken pre-, mid- and post intervention. RESULTS: Participants undergoing the 10-week mindfulness training program reported greater improvements in stress and burnout relative to participants in the control condition. Significant reduction in stress and burnout was observed for participants in the mindfulness condition. No such reductions were observed for participants in the control condition. CONCLUSIONS: Mindfulness interventions may provide medical practitioners with skills to effectively manage stress and burnout, thereby reducing their experience of these symptoms. It is likely that doctors would benefit from the inclusion of such a training program as a part of their general medical education.

Internet-Based Delivery of Cognitive Behaviour Therapy Compared to Monitoring, Feedback and Support for Problem Gambling: A Randomised Controlled Trial.

The aim of this study was to investigate the efficacy of an Internet-based cognitive behavioural therapy program (I-CBT) for the treatment of problem gambling, when compared to a waitlist control and an active comparison condition consisting of monitoring, feedback, and support (I-MFS). Participants (N = 174) were randomly allocated to the three conditions. Variables of interest were gambling outcome and related mental health measures. Participants in the active conditions (I-CBT and I-MFS) completed six online modules. Both I-CBT and I-MFS conditions resulted in significant treatment gains on gambling severity. However, I-CBT was also associated with reductions in a range of other gambling-related and mental health outcomes. Compared with I-MFS, I-CBT produced greater effects across seven outcomes measures, relating to gambling urges, cognitions, stress, and life satisfaction. I-CBT participants also rated the program as significantly more satisfactory. Treatment gains observed for both active conditions were found to be stable through to 12 month follow up. The results indicate that the benefits of I-CBT were more than simply the non-specific effects of engaging in online treatment or receiving motivation, feedback, and support. Online treatments for gambling may be a valuable tool in increasing help-seeking and treatment engagement in this population, and be integrated as part of stepped care approaches to treatment.

Assessing treatment barriers in eating disorders: A systematic review.

This systematic review evaluated methods used to assess treatment barriers among individuals with eating disorders or disordered eating. A total of 11 studies were identified and evaluated according to attributes considered important in the accurate assessment of treatment barriers. The majority of studies used qualitative methods, with five studies utilizing either a checklist or scale-based instrument. Adequate psychometric investigation was lacking. This review highlights the paucity of research examining barriers to accessing and/or receiving treatment in disordered eating populations. There is a need for development of psychometrically sound instruments that assess the range and relative interference of specific barriers experienced in this population.

Using SMS reminders in psychology clinics: a cautionary tale.

BACKGROUND: As healthcare services become progressively more stretched, there is increasing discussion of ways in which technological adjuncts may be used to deliver more cost-efficient services. Before widespread implementation, however, the use of these adjuncts requires proper scrutiny of their effects on psychological practice. AIMS: This research examined the effectiveness of SMS reminders on client appointment attendance and dropout in a psychological treatment setting. It was predicted that the reminders would result in increased initial appointment attendance, increased total appointment attendance, and decreased client dropout. METHOD: A randomized controlled trial investigated the impact of SMS appointment reminders (two levels: present or absent) on client attendance (three levels: attended, rescheduled, or did not attend) and dropout (two levels: completed treatment or terminate early). Participants (N = 140) at an outpatient psychology clinic were randomly allocated to either receive an SMS appointment reminder one day before their scheduled appointment, or to receive no reminder. RESULTS: No significant differences were found between the SMS and no SMS conditions in relation to appointment attendance. There were more client dropouts in the SMS compared to the no SMS condition. CONCLUSIONS: The SMS appointment reminders were not effective at increasing appointment attendance. The current research suggests that there is more to client non-attendance in psychological settings than the simple forgetting of appointments. Technological adjuncts may be useful in increasing the cost-efficiency of current services; however, this research highlights the importance of understanding the effects of technology before widespread implementation.

Measuring mental health literacy--a review of scale-based measures.

BACKGROUND: Mental Health Literacy (MHL) has become an important concept in the literature; however, quantitative research on MHL methodology has been limited. AIMS: This review identified peer-reviewed papers investigating MHL, assessed psychometric attributes of scale-based measures of MHL, and the extent that studies assessed the attributes that define MHL. METHOD: A comprehensive review of the literature was conducted to identify measures which generate a total MHL or subscale score was also conducted. A total of 13 studies were identified and their psychometric attributes determined using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN). The extent to which each measure assessed the attributes of MHL was also determined. RESULTS: Results showed that included studies failed to report detailed information about the sample, measure development and testing to demonstrate the psychometric properties of their tool. CONCLUSION: There are substantial limitations in current ability to measure MHL and there is significant scope for the development and evaluation of psychometrically robust measures that assess the relevant attributes of MHL. Further research could also focus on the adequacy of the current definition of MHL.

Can you tell me more about that? An examination of self-disclosure in videoconference and face-to-face psychological interviewing.

OBJECTIVES: Videoconference psychotherapy (VCP) is a crucial component of many health care systems, allowing for remote delivery of services. However, little is known about the mechanisms of change within VCP. Previous research has suggested that self-disclosure may be greater in VCP than face-to-face modalities and was investigated in the current study. DESIGN: Young adults aged 18-25 years (N = 57) were randomly allocated to face-to-face or VCP interview conditions, with measures completed pre- and post-interview. METHODS: Participants completed an autobiographical memory task, requiring them to describe specific memories in response to positive and negative valence cue words. Measures included self-reported self-disclosure, blind observer-rated self-disclosure, memory specificity, and mean number of words per response. RESULTS: No significant differences were found between conditions with regard to self-reported self-disclosure, capacity to recall specific memories, or words uttered per response. However, observer-rated depth of self-disclosure was significantly higher for participants in the face-to-face than VCP condition. Self-disclosure and memory specificity were also significantly greater for negative than positive valence cue words, regardless of condition. CONCLUSIONS: The findings indicate that whilst participants may be able to draw on memories with equal ease regardless of interview modality, in VCP, emotional processing of these memories may require increased support and guidance from the therapist.

Working together: An investigation of the impact of working alliance and cohesion on group psychotherapy attendance.

OBJECTIVES: Group psychotherapy holds considerable potential for cost-effective treatment delivery. However, issues with client attendance can compromise the efficacy of such treatments. To date, client specific factors are amongst the most researched predictors of attendance in psychotherapy, with much less of a focus given to process factors, particularly in the group therapy context. This study aimed to determine which process factors influenced attendance in the context of a group therapy programme for adults with anxiety. It was hypothesized that (1) the working alliance and group cohesion would be moderately correlated, (2) both the working alliance and group cohesion would explain unique variance in session attendance, and (3) the working alliance would act as a moderator for attendance, when group cohesion was low. DESIGN: The study utilized a within participants design. METHODS: Participants were 91 adults (aged 18-74 years) who took part in a 9-week, transdiagnostic cognitive behavioural group therapy programme for the treatment of anxiety disorders. RESULTS: Working alliance and group cohesion were significantly, but only moderately correlated (rs ranging .41 to .55). Together, working alliance and group cohesion significantly predicted total session attendance (17.70% variance explained). Working alliance did not moderate the relationship between group cohesion and session attendance. CONCLUSIONS: The importance of individual and group processes in influencing group therapy engagement is highlighted, including the role of fostering bonds within the group and between clients and therapists. PRACTITIONER POINTS: A complex array of process factors has been argued to influence treatment outcomes in group therapy The quality of the relationship between group therapy clients, as well as the relationship between a client and the therapist, predict session attendance. The quality of the relationship between the client and the therapist may be the most important predictor of session attendance. Therapists should foster positive relationships between each client and the therapist in group therapy, as well as assisting each client to foster positive relationships with other group members.

A Decade in Review: A Systematic Review of Virtual Reality Interventions for Emotional Disorders.

Research is increasingly demonstrating the therapeutic benefits of virtual reality interventions for various mental health conditions, though these rarely translate from research to application in clinical settings. This systematic review aims to examine the efficacy of current virtual reality interventions for emotional disorders, with a focus on clinical and technological features that influence translation of treatments from research to clinical practice. A comprehensive systematic literature search was conducted following PRISMA guidelines, for studies including the application of a virtual reality intervention to a clinical population of adults with an emotional disorder. Thirty-seven eligible studies were identified, appraised, and assessed for bias. Treatment effects were typically large across studies, with virtual reality being considered an efficacious treatment modality for various anxiety disorders and post-traumatic stress disorder. Virtual reality interventions were typically used for delivering exposure in cognitive behavioural therapy approaches. Considerable variability was seen in cost, technological specifications, degree of therapist involvement, delivery format, dosage, duration, and frequency of treatment. Suboptimal methodological rigour was identified in some studies. Remote use of virtual reality was rare, despite increasing options for in home use. Virtual reality interventions have the potential to overcome barriers to care and better meet the needs of consumers. Future research should examine the efficacy of virtual reality for treatment of depressive disorders and obsesive compulsive disorder. Improved methodological reporting and development of transdiagnostic and remotely delivered virtual reality interventions, will likely increase the translation of this treatment modality.

Cada vez más la investigación demuestra las ventajas terapéuticas de las intervenciones mediante realidad virtual en distintos estados de salud mental, aunque esta investigación raramente se traslada a la aplicación en el contexto clínico. Esta revisión sistemática pretende analizar la eficacia de las intervenciones actuales de realidad virtual en trastornos emocionales, centrándose en las características clínicas y tecnológicas que afectan a la transferencia de los tratamientos desde la investigación hasta la práctica clínica. Se llevó a cabo una amplia búsqueda bibliográfica sistemática de acuerdo con las directrices PRISMA para estudios que abarcan la aplicación de la intervención mediante realidad virtual a población clínica adulta con trastornos emocionales. Se consideraron elegibles 37 estudios, que fueron valorados y revisados para descartar sesgos. Los efectos de los tratamientos eran normalmente grandes, siendo considerada la realidad virtual como una modalidad de tratamiento eficaz para diversos trastornos de ansiedad y el de estrés postraumático. Las intervenciones de realidad virtual normalmente se han utilizado para la exposición en los enfoques de terapia cognitivo-conductual. Se observó una considerable variabilidad en coste, especificaciones tecnológicas, grado de implicación del terapeuta, formato de presentación, dosificación, duración y frecuencia del tratamiento. En algunos estudios se observó que el rigor metodológico estaba por debajo de los niveles óptimos. La utilización remota de realidad virtual no era frecuente a pesar de las posibilidades que ofrece para usarse en casa. Las intervenciones de realidad virtual tienen el potencial de superar barreras en los cuidados y cubrir mejor las necesidades de los consumidores. La investigación futura debería analizar la eficacia de la realidad virtual para tratar los trastornos depresivos y el desorden obsesivo compulsivo. Mejorar los informes metodológicos y el desarrollo de las intervenciones mediante realidad virtual transdiagnósticas y practicadas a distancia podría facilitar la transferencia de esta modalidad de tratamiento.