Increasing Acceptability and Outcome Expectancy for Internet-Based Cognitive Behavioral Therapy During the COVID-19 Pandemic.

Background:e-Health interventions for mental health have the potential to reduce burdens on health care systems, but large survey studies find low acceptability for these interventions. The COVID-19 pandemic may make attitudes toward e-health more malleable. The current study examined whether an intervention to improve attitudes toward Internet-based cognitive behavioral therapy (iCBT) has a greater impact during the COVID-19 pandemic than before the pandemic.Materials and Methods:Individuals (N = 662) recruited from a large university and surrounding community who participated in a study about the acceptability of iCBT in 2018 and 2019 were asked to participate in a follow-up survey. In the original study, participants were randomized to receive or not receive a rationale designed to increase acceptability of iCBT, and then they completed measures of acceptability and outcome expectancy for iCBT. Fifty-one participants enrolled in the follow-up study from May to July 2020. They received a treatment rationale for iCBT (or not) in keeping with randomization from the parent study and re-completed measures assessing the acceptability and outcome expectancy for iCBT.Results:Contrary to hypotheses, two-way analyses of covariance (ANCOVA's) demonstrated that there was no significant interaction between time point and rationale condition on acceptability or outcome expectancy for iCBT. There was a significant main effect of rationale condition on acceptability, such that participants who received a treatment rationale reported greater acceptability for iCBT. There were no significant main effects of time.Conclusions:A treatment rationale was effective in improving acceptability for iCBT in a general population sample, but not more so during the COVID-19 pandemic.

The use of trial-level bias scores to examine attention bias and attention bias variability among people with and without social anxiety disorder.

BACKGROUND: Cognitive models of anxiety propose that people with anxiety disorders show elevated levels of attention bias toward threat, but the most commonly used index of attention bias, which measures the construct with an aggregate score of multiple trials across an experimental session, shows poor test-retest reliability. Newer indices that measure attention bias dynamically on a trial-to-trial basis show good reliability and enable researchers to measure not only overall attention bias toward threat, but also attention bias variability. METHODS: The current study tested the hypothesis that people diagnosed with social anxiety disorder would show higher attention bias variability and higher attention bias toward threat when calculated dynamically and when calculated using the traditional aggregate index. Participants diagnosed with social anxiety disorder (n = 47) and controls (n = 57) completed a 160-trial version of the dot-probe task using emotional and neutral images of faces as stimuli. RESULTS: Relative to controls, participants diagnosed with social anxiety disorder showed higher mean bias toward threat, but only when calculated using trial-level bias scores. There were no differences between groups on attention bias variability. DISCUSSION: This is the first study to examine differences in attention bias and attention bias variability between people with and without social anxiety disorder using trial-level bias scores. Results suggest that attention bias, but not attention bias variability, is a feature of social anxiety psychopathology and that trial-level bias scores may be more sensitive than aggregated mean scores to detect it. These findings have implications for clinical interventions such as attention bias modification programs, which require precise measures of attention bias to accurately assess treatment outcomes.

Integrating virtual realities and psychotherapy: SWOT analysis on VR and MR based treatments of anxiety and stress-related disorders.

The use of virtual reality (VR) and mixed reality (MR) technology in clinical psychology is growing. Efficacious VR-based treatments for a variety of disorders have been developed. However, the field of technology-assisted psychotherapy is constantly changing with the advancement in technology. Factors such as interdisciplinary collaboration, consumer familiarity and adoption of VR products, and progress in clinical science all need to be taken into consideration when integrating virtual technologies into psychotherapies. We aim to present an overview of current expert opinions on the use of virtual technologies in the treatment of anxiety and stress-related disorders. An anonymous survey was distributed to a select group of researchers and clinicians, using an analytic framework known as Strengths, Weaknesses, Opportunities, and Threats (SWOT). Overall, the respondents had an optimistic outlook regarding the current use as well as future development and implementation of technology-assisted interventions. VR and MR psychotherapies offer distinct advantages that can overcome shortcomings associated with traditional therapy. The respondents acknowledged and discussed current limitations of VR and MR psychotherapies. They recommended consolidation of existing knowledge and encouraged standardisation in both theory and practice. Continued research is needed to leverage the strengths of VR and MR to develop better treatments.Abbreviations: AR: Augmented Reality; MR: Mixed Reality; RCT: Randomised Controlled Trial; SWOT: Strengths, Weaknesses, Opportunities, and Threats; VR: Virtual Reality; VR-EBT: Virtual Reality Exposure-Based Therapy.

The course of the working alliance during virtual reality and exposure group therapy for social anxiety disorder.

BACKGROUND: Psychoanalytic theory and some empirical research suggest the working alliance follows a "rupture and repair" pattern over the course of therapy, but given its emphasis on collaboration, cognitive behavioral therapy may yield a different trajectory. AIMS: The current study compares the trajectory of the working alliance during two types of cognitive behavioral therapy for social anxiety disorder - virtual reality exposure therapy (VRE) and exposure group therapy (EGT), one of which (VRE) has been proposed to show lower levels of working alliance due to the physical barriers posed by the technology (e.g. no eye contact with therapist during exposure). METHOD: Following randomization, participants (N = 63) diagnosed with social anxiety disorder received eight sessions of manualized EGT or individual VRE and completed a standardized self-report measure of working alliance after each session. RESULTS: Hierarchical linear modeling showed overall high levels of working alliance that changed in rates of growth over time; that is, increases in working alliance scores were steeper at the beginning of therapy and slowed towards the end of therapy. There were no differences in working alliance between the two treatment groups. CONCLUSION: Results neither support a rupture/repair pattern nor the idea that the working alliance is lower for VRE participants. Findings are consistent with the idea that different therapeutic approaches may yield different working alliance trajectories.

Stereotype confirmation concerns predict dropout from cognitive behavioral therapy for social anxiety disorder.

BACKGROUND: There are high attrition rates observed in efficacy studies for social anxiety disorder, and research has not identified consistent nor theoretically meaningful predictors of dropout. Pre-treatment symptom severity and demographic factors, such as age and gender, are sometimes predictive of dropout. The current study examines a theoretically meaningful predictor of attrition based on experiences associated with social group membership rather than differences between social group categories--fear of confirming stereotypes. METHODS: This is a secondary data analysis of a randomized controlled trial comparing two cognitive behavioral treatments for social anxiety disorder: virtual reality exposure therapy and exposure group therapy. Participants (N = 74) with a primary diagnosis of social anxiety disorder who were eligible to participate in the parent study and who self-identified as either "African American" (n = 31) or "Caucasian" (n = 43) completed standardized self-report measures of stereotype confirmation concerns (SCC) and social anxiety symptoms as part of a pre-treatment assessment battery. RESULTS: Hierarchical logistic regression showed that greater stereotype confirmation concerns were associated with higher dropout from therapy--race, age, gender, and pre-treatment symptom severity were not. Group treatment also was associated with higher dropout. CONCLUSIONS: These findings urge further research on theoretically meaningful predictors of attrition and highlight the importance of addressing cultural variables, such as the experience of stereotype confirmation concerns, during treatment of social anxiety to minimize dropout from therapy.

Discrepancies in therapist and client ratings of global improvement following cognitive behavioral therapy for social phobia and their differential relations with symptom improvement at post-treatment and 12-month follow-up.

OBJECTIVE: This study aimed to examine discrepancies in client and therapist ratings of global improvement and their relations to symptom improvement at post-treatment and 12-month follow-up. METHOD: Participants (N = 59) with social phobia received eight sessions of cognitive behavioral therapy (CBT). Participants and therapists rated improvement following each session. Participants also rated improvement at follow-up. Participants completed symptom severity self-reports at post-treatment and follow-up. RESULTS: Clients consistently rated themselves as more improved than therapists. Relative to client ratings, therapist post-treatment ratings of improvement were related to more indices of symptom change at both timepoints. CONCLUSIONS: RESULTS suggest that therapist ratings have good predictive utility of client-reported change in symptoms.

The relation between mindfulness and fear of negative evaluation over the course of cognitive behavioral therapy for social anxiety disorder.

OBJECTIVES: This study examined the relation between mindfulness and fear of negative evaluation over the course of nonmindfulness based cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD). We expected that higher levels of mindfulness would be associated with a more positive response to treatment. METHOD: This study is a secondary report from a randomized controlled trial in which participants (N = 65) diagnosed with SAD were randomly assigned to receive 8 weeks of 1 of 2 manualized treatments (exposure group therapy, n = 33; or virtual reality exposure therapy, n = 32) either immediately or following an 8 week waiting period. RESULTS: Fear of negative evaluation decreased following treatment and was negatively related to mindfulness throughout treatment and follow-up. Mindfulness did not moderate treatment outcome. CONCLUSIONS: These findings indicate that while mindfulness is related to fear, it is not a moderator of symptom reduction in nonmindfulness-based treatment. Implications for treatment and future research are discussed.

A qualitative exploration of college students' experiences using mobile apps to improve self-care during the COVID-19 pandemic.

Objective: This project examines students' experiences using a mental health mobile application (app) as part of a class assignment developed to support student well-being. Participants: Data was collected from 265 undergraduate students enrolled in a psychology course during the COVID-19 pandemic. Methods: Students developed a self-care goal and used an app to support progress toward it. Thematic analysis was applied to students' written reflections about their experiences using the app and practicing self-care. Results: Students reported using an app for self-care was 1) more helpful than expected for improving focus, productivity, motivation, sleep, and mental health symptoms; 2) challenging due to loss of interest, slow improvement, difficulty integrating into routine, or negative feelings triggered; and 3) influenced by the pandemic and transition to remote learning. Conclusions: A classroom assignment designed to promote self-care using a mental health app shows promise. Future research is needed to better understand engagement and impact.

User experiences of college students using mental health applications to improve self-care: Implications for improving engagement.

The purpose of this study is to evaluate themes on 'user experiences' among college students (N = 265) enrolled in an upper-division Psychopathology course who were assigned a project in which they were instructed to identify a self-care goal, choose from a list of six mental health-focused mobile applications (apps) provided by the instructor, and use the app over the course of three weeks to support progress towards their goal. Prior literature on user experiences typically evaluates user reviews, or asks participants to reflect on past app use or anticipate future use. Students reported their experiences using the app during key decision points: app selection, while using the app, and at the conclusion of the assignment. Using thematic analysis, results identified seven central themes and eight subthemes pertaining to the content of the app (e.g., app features) and the context of using the app (e.g., classroom assignment). Content-wise students liked: 1) features with a strong evidence base, namely, thought diaries and guided meditations; 2) progress tracking, because it increased awareness of mood/stressors, motivated students to see improvement, and helped them stay on track. Students appreciated having 3) crisis support resources; 4) app interfaces that allowed for customization (poor app interfaces were sometimes cited as the reason for disengagement); and 5) apps that included varied, comprehensive resources such that it felt like a one-stop shop. In addition to the content of features and design interface, the context in which mental health apps are introduced and used is important. The remaining themes related to the context in which the app was used, including 6) preparation for app usage, such as reviewing scholarly/credible sources, and 7) social support from fellow students completing the same assignment. Future research should evaluate the 'who, what, when, why, where, and how' of app utilization during key decision points, such as initial app selection or subscription renewal, to better understand the impact of user experience on engagement.

A pilot study of attention bias subtypes: examining their relation to cognitive bias and their change following cognitive behavioral therapy.

OBJECTIVE: The present investigation examined (a) whether a clinical sample of individuals with social anxiety disorder (SAD) comprises two distinct groups based on attention bias for social threat (vigilant, avoidant), (b) the relation between attention bias and cognitive bias, specifically estimates of the probability that negative social events will occur (probability bias), and (c) specific changes in attention bias following cognitive behavioral therapy for social anxiety. METHOD: Participants were 24 individuals (nfemale = 7, nmale = 17; mage = 41) who met diagnostic criteria for SAD and sought treatment for fear of public speaking. Hypotheses were tested using t tests, linear regression analyses, and a mixed design analysis of variance. RESULTS: Results yielded evidence of 2 pretreatment groups (vigilant and avoidant). There was a significant positive correlation between vigilance for (but not avoidance of) threat and probability bias (R = .561, p < .05). After 8 weeks of treatment, the direction of change in attention bias differed between groups, such that the vigilant group became less vigilant and the avoidant group became less avoidant, with the avoidant group showing a significant change in attention bias from pretreatment to posttreatment. CONCLUSIONS: These findings provide very preliminary support for the idea that individuals with SAD may differ according to type attention bias, avoidant or vigilant, as these biases changed in different ways following cognitive-behavioral therapy for SAD. Further research is needed to replicate and extend these findings in order to evaluate whether SAD comprises subgroups of attentional biases.

Cognitive processes mediate the relation between mindfulness and social anxiety within a clinical sample.

OBJECTIVES: The researchers investigated the relation between mindfulness and social anxiety symptoms, and examined whether this relation is mediated by cognitive appraisals commonly associated with social anxiety. PARTICIPANTS: Ninety-eight individuals diagnosed with social phobia. DESIGN: Using a cross-sectional design, ordinary least squares regression and bootstrapping mediation analyses were used to test the study hypotheses. RESULTS: Mindfulness was negatively related to symptoms of social anxiety. This relation was partially mediated by cognitive appraisals about the likelihood and cost of a negative social outcome. CONCLUSION: Further research using a longitudinal design and other measures of mindfulness is needed to replicate these findings and further explicate the mechanism by which mindfulness might be associated with negative cognitive appraisals.

A novel computer task to assess outcome probability bias.

This research describes the development of a novel computer task to assess outcome probability bias for social anxiety - the tendency to make unrealistically high evaluations of the probability of experiencing a negative outcome when anticipating a social encounter - that improves upon existing measures by using images and by assessing the construct at automatic and controlled levels of processing. The first study evaluated the images selected for the task and the extent to which the task elicited automatic responding, and the second study evaluated the task's reliability and validity. Across both studies, 203 college students completed the outcome probability bias computer task, standardized self-report questionnaires of outcome probability bias, outcome cost bias, depression and stress, and safety behaviors, and completed a behavioral avoidance task. The task demonstrated good to excellent internal consistency (α = 0.82 - 0.96) and significant positive correlations with a standardized measure of outcome probability bias (r = 0.33 - 0.48). With one exception, all hypotheses regarding the convergent, discriminant, construct, and criterion validity of the task were supported. Pending replication and additional evaluation, the outcome probability bias computer task may advance research on social anxiety disorder and may be adapted for use with other related disorders.

Culturally adapted digital mental health interventions for ethnic/racial minorities: A systematic review and meta-analysis.

OBJECTIVE: Digital mental health interventions (DMHIs) are typically designed as "one-size fits all" which may perpetuate health disparities for racialized minorities. This systematic review identified culturally adapted DMHIs and examined their efficacy and acceptability among racial and ethnic minorities. METHOD: PsycINFO, Web of Science, and Pubmed databases were searched between 2000 and 2021. Studies that examined the development or impact of a culturally adapted DMHI for racial or ethnic minority populations using quantitative and/or qualitative methodologies were included. Meta-analyses explored the efficacy of DMHIs, and moderator analyses were used to identify differences in effect sizes due to study quality, clinical outcomes, therapist support, and attrition. RESULTS: Thirty-two studies met inclusion criteria and were reviewed. DMHIs were deemed acceptable and feasible in most studies (n = 24). Among eligible randomized controlled studies (n = 12) comprising 653 participants, results indicated that culturally adapted DMHIs produced a large, positive, significant effect (g = 0.90) across a range of outcomes when compared to wait-list and treatment as usual control conditions. The average attrition rate per study was 42%, and most participants did not complete all modules despite reporting high satisfaction. CONCLUSIONS: Culturally adapted DMHIs are efficacious and acceptable. Such interventions represent a powerful opportunity to circumvent barriers to mental health treatment and improve mental health equity among racially and ethnically minoritized communities. However, the prevalence of feasibility studies, lack of active comparison treatments-and limited research for Black and Indigenous populations-indicate that more research is needed to achieve this purpose. Recommendations are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Vigilant and avoidant attention biases as predictors of response to cognitive behavioral therapy for social phobia.

BACKGROUND: Attention bias for socially threatening information, an empirically supported phenomenon, figures prominently in models of social phobia. However, all published studies examining this topic to date have relied on group means to describe attention bias patterns; research has yet to examine potential subgroups of attention bias among individuals with social phobia (e.g., vigilant or avoidant). Furthermore, almost no research has examined how attention biases in either direction may predict change in symptoms as a result of treatment. METHODS: This study (N = 24) compared responses to cognitive behavioral therapy (CBT) for social phobia between individuals with avoidant and vigilant biases for threatening faces at pretreatment. RESULTS: Participants with avoidant biases reported significantly and clinically higher symptom levels at posttreatment than did those with vigilant biases. CONCLUSIONS: These findings suggest that an avoidant attention bias may be associated with reduced response to CBT for social phobia.

Engagement with mobile health interventions for depression: A systematic review.

BACKGROUND: Depressive disorders are a major public health problem, and many people face barriers to accessing evidence-based mental health treatment. Mobile health (mHealth) interventions may circumvent logistical barriers to in-person care (e.g., cost, transportation), however the symptoms of depression (low motivation, concentration difficulties) may make it difficult for people with the disorder to engage with mHealth. OBJECTIVE: The aim of this systematic review is to examine assessment and reporting of engagement in clinical trials of mHealth interventions for depression, including objective engagement (e.g., number of times program is used), subjective engagement (e.g., qualitative data on users' experiences), and associations between engagement and other clinically important variables (e.g., symptom improvement, participant characteristics). METHODS: Three electronic databases (PsycINFO, Web of Science, PubMed) were searched in February 2020 using search terms for mHealth and depression. Studies were included in the review if they tested a mHealth intervention designed for people with depressive disorders or elevated depression symptoms. RESULTS: Thirty studies met inclusion criteria and were reviewed. Most studies reported objective engagement (N = 23, 76.7%), approximately half reported subjective engagement (N = 16, 53.3%), and relatively few examined associations between engagement and clinical improvement, participant characteristics, or other clinically relevant variables (N = 13, 43.3%). CONCLUSIONS: Although most studies in this small but rapidly growing literature report at least one measure of engagement, there is substantial heterogeneity. Intentional, theory-driven, and consistent measurement of engagement with mHealth interventions for depression may advance the field's understanding of effective engagement to facilitate clinical improvement, identify dose-response relationships, and maximize generalizability for underserved populations.

Improving Acceptability and Uptake Behavior for Internet-Based Cognitive-Behavioral Therapy.

Internet-based cognitive behavioral therapy (iCBT) programs have the potential to improve access to mental healthcare, but they are not viewed as acceptable nor widely utilized by the general public. This study tested whether two acceptance-facilitating interventions improved acceptability and uptake-related behavior for therapist assisted and self-guided iCBT. Participants were randomly assigned to read a treatment rationale for iCBT (vs. a brief definition) and to receive a small financial incentive (or not) for seeking more information about evidence-based iCBT programs. Participants (N = 662) were a diverse group recruited from a University participant pool and the surrounding community. Participants completed standardized measures of attitudes toward and outcome expectancy for iCBT and a single question about willingness to use it and were given the opportunity to get information about accessing evidence-based iCBT programs. A series of MANCOVAs showed small, positive effects of the treatment rationale on attitudes and outcome expectancy for both self-guided and therapist-assisted iCBT, but not for willingness to use it. A hierarchical logistic regression model found no effect of the treatment rationale or financial incentive on whether participants sought additional information about how to access iCBT, although psychopathology symptoms and identifying as White or multiracial were positively associated with information-seeking. Inconsistent with past research, participants rated therapist-assisted and self-guided iCBT as equally acceptable. Participants recruited from the community reported greater willingness to use iCBT than University students. These results underscore the urgent need for further research toward improving the acceptability and uptake of iCBT so that it may better fulfill its potential to fill the gap in unmet mental health need.

Maximizing the impact of virtual reality exposure therapy for anxiety disorders.

The impact of virtual reality on access to exposure therapy and recovery from anxiety is unrealized, but an argument can be made that this is about to change. Virtual reality exposure therapy for anxiety disorders is safe, effective, and, in most cases, as effective as in vivo exposure therapy. Clinician attitudes toward virtual reality are now more positive than negative. Moderately priced virtual reality systems are commercially available. Self-guided and fully automated programs for specific fears are new, scalable, potentially game-changing developments. Future research that assesses cultural bias and external validity will position virtual reality exposure therapy to address mental health disparities, to realize its potential to increase access to effective treatment for anxiety disorders, and to improve public health.

Evaluating the reliability of attention bias and attention bias variability measures in the dot-probe task among people with social anxiety disorder.

The dot-probe task is a widely used experimental paradigm that evaluates attention biases within anxiety disorders. Considerable research has focused on improving the reliability of dot-probe scores because the task's original attention bias index has shown very low test-retest reliability. The current study serves as a replication and extension of Price et al. (2015), who systematically examined the effects of methodological choices on reliability of dot-probe task results. Fifty-six adults diagnosed with social anxiety disorder were asked to complete a facial dot-probe task twice, approximately 1 week apart. Test-retest reliability and internal consistency were examined for 10 dot-probe attention bias indices across 55 sets of outlier cutoffs. Both Pearson's r and intraclass correlation coefficients were used. Trial-level bias score indices of mean bias toward threat and attention bias variability, which measure attention bias dynamically using individual pairs of trials, demonstrated the highest reliability and were less sensitive to changes in outlier cutoffs as compared with the dot probe's classic attention bias index and others. Results demonstrate the potential for post hoc outlier cutoff selection to artificially inflate reliability, particularly for unreliable indices. A priori cutoff selection is recommended for future research. Intraclass correlation coefficients are also recommended for assessment of reliability because Pearson's r does not account for poor agreement between scores. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Amygdala volume and social anxiety symptom severity: Does segmentation technique matter?

The amygdala factors prominently in neurobiological models of social anxiety (SA), yet amygdala volume findings regarding SA have been inconsistent and largely focused on case-control characterization. One source of discrepant findings could be variability in volumetric techniques. Therefore, we compared amygdala volumes derived via an automated technique (Freesurfer) against a manually corrected approach, also involving Freesurfer. Additionally, we tested whether the relationship between volume and SA symptom severity would differ across volumetric techniques. We pooled participants (n = 76) from archival studies. SA severity was assessed with the Liebowitz Social Anxiety Scale; scores ranged from non-clinical to clinical levels. Freesurfer produced significantly larger amygdalar volumes for participants with poor image quality. Even after excluding such participants, paired sample t-tests showed Freesurfer's boundaries produced significantly larger amygdalar volumes than manually corrected ones, bilaterally. Yet, intra-class correlation coefficients between the two methods were high, which suggests that Freesurfer's over-estimation of amygdala volume was systemic. Regardless of segmentation technique, volumes were not associated with SA symptom severity. Potentially, amygdala sub-regions may yield clearer patterns regarding SA symptoms. Further, our study underscores the importance of image quality for segmentation of the amygdala, and image quality may be particularly valuable when examining anatomical data for subtle inter-individual differences.

A meta-analytic examination of attrition in virtual reality exposure therapy for anxiety disorders.

A proposed advantage of virtual reality exposure therapy for anxiety disorders is that people will be less likely to drop out of treatment prematurely if the treatment involves facing one's fear in a virtual world rather than the real world, but this has yet to be empirically tested. The present meta-analyses assess the odds of dropout from virtual reality exposure therapy compared to in vivo exposure therapy, estimate the overall rate of dropout from virtual reality exposure treatment, and test potential moderating variables. The odds ratio meta-analysis indicated that there was no significant difference in the likelihood of attrition from virtual reality exposure therapy relative to in vivo exposure therapy. The overall attrition rate for virtual reality exposure therapy across 46 studies with a combined sample size of 1057 participants was 16%. This rate is slightly lower than other estimates of dropout from in vivo therapy and from cognitive-behavioral therapy for anxiety disorders. Incorporation of between-session intervention (i.e., homework) was identified as a moderator; specifically, inclusion of between-session interventions in the treatment was associated with better retention. Overall, the findings of the present study indicate that virtual reality exposure and in vivo exposure therapy show similar rates of attrition.