Implementation of a brief online skills group of dialectical behaviour therapy for emotional dysregulation in Latinx: a withdrawal experimental single-case design.

BACKGROUND: Dialectical behaviour therapy (DBT) skills groups have shown promise as an effective treatment for clients with emotional dysregulation, especially when combined with individual DBT. However, their efficacy is not well established as an online therapy, or in the Latinx population. AIMS: This study aimed to explore satisfaction, retention and effects of an internet-based DBT group added to individual online sessions. METHOD: An ABAB withdrawal experimental single-case design was conducted to evaluate the effect of a brief online DBT skills group on emotional dysregulation, anxiety and depression for five Latinx participants. DBT skills group (phase B) were compared with placebo group sessions (phase A) and fortnightly individual DBT sessions were offered throughout to manage risk. RESULTS: Visual inspection showed a decrease in level of emotional dysregulation and a large effect size according to the Nonoverlap of All Pairs when comparing group DBT and placebo phases. Although depression symptoms decreased after introducing group DBT, anxiety indicators decreased most during the second round of group placebo sessions. DISCUSSION: Whilst only a pilot, this study suggests that online group DBT in Latinx populations is feasible and effective for changing emotional regulation processes but may not effectively target anxiety. Future research might increase the number of DBT sessions in order to enhance learning opportunities and generalization. Replication with larger sample sizes and diverse modalities is needed.

How a transdiagnostic approach can improve the treatment of emotional disorders: Insights from clinical psychology and neuroimaging.

Multiple psychological treatments for emotional disorders have been developed and implemented, improving the quality of life of individuals. Nevertheless, relapse and poor response to psychotherapy are common. This article argues that a greater understanding of both the psychological and neurobiological mechanisms of change in psychotherapy is essential to improve treatment for emotional disorders. It aims to demonstrate how an understanding of these mechanisms provides a basis for (i) reconceptualizing some mental disorders, (ii) refining and establishing the evidence for existing therapeutic techniques and (iii) designing new techniques that precisely target the processes that maintain these disorders. Possible future directions for researchers and practitioners working at the intersection of neuropsychology and clinical psychology are discussed.

Abuse, invalidation, and lack of early warmth show distinct relationships with self-criticism, self-compassion, and fear of self-compassion in personality disorder.

BACKGROUND: Cultivating self-compassion is increasingly recognized as a powerful method to regulate hyperactive threat processes such as shame and self-criticism, but fear of self-compassion (FSC) can inhibit this. These difficulties are underexplored in personality disorder (PD) despite their prevalence. Furthermore, little evidence exists regarding how these factors relate to adverse childhood experiences (ACEs) and attachment. METHOD: Fifty-three participants with a diagnosis of PD completed measures including childhood abuse/neglect, invalidation, early warmth, self-compassion, shame, self-criticism, FSC, and anxious/avoidant attachment. RESULTS: Self-compassion was predicted uniquely by low early warmth; self-inadequacy by invalidation and abuse; and FSC by multiple ACEs. FSC and self-compassion were significantly correlated with self-criticism and shame, but not with one another. CONCLUSIONS: Low self-compassion and high FSC appear to be distinct problems, substantiating physiological models proposing distinct threat and soothing systems. Results are consistent with theories positing that low self-compassion has distinct origins to shame, self-criticism, and FSC.

Inhibitors and facilitators of compassion-focused imagery in personality disorder.

BACKGROUND: Compassion-focused therapy (CFT) has potential to benefit clients with a personality disorder (PD), given the inflated levels of shame and self-criticism in this population. However, clinical observation indicates that clients with PD may find techniques from this approach challenging. AIMS: The aim of this study is to trial one aspect of CFT, compassion-focused imagery (CFI), with this population, and identify factors that predict clients' ability to generate CFI and experience self-compassion during the task, including type of CFI exercise and, second, to establish whether CFI outcomes increase with practice. METHOD: In Study 1, 53 participants with a diagnosis of PD completed measures of self-compassion, self-reassurance, shame, self-criticism, fear of self-compassion, affect, anxious and avoidant attachment, and mental imagery abilities. Participants were assigned to trial CFI from memory (n = 25) or from imagination (n = 28), then rated their image's vividness, its compassionate traits, and ease of experiencing compassion. A negative mood manipulation was carried out, and CFI tasks and outcome measures were repeated. For Study 2, self-compassion and self-criticism were measured before and after 1 week of daily CFI practice. RESULTS: Study 1 found that negative mood and low mental imagery ability are significant inhibitors to generating compassionate images and affect. The 2 CFI exercises were equally effective. Study 2 suffered from high attrition, but regular practice was associated with significant improvement in self-compassion (though not self-criticism). CONCLUSIONS: CFI appears to be effective in improving self-compassion for some clients. However, it is less effective in the presence of negative affect. Clients with low mental imagery ability may benefit more from alternative CFT techniques.

Outcome of Intensive Cognitive Behaviour Therapy in a Residential Setting for People with Severe Obsessive Compulsive Disorder: A Large Open Case Series.

BACKGROUND: There is little data to inform the treatment of severe obsessive compulsive disorder (OCD) in an inpatient or residential setting. AIMS: This paper aimed to: a) describe treatment outcomes at a residential unit over 11 years; b) investigate whether treatment was successful for a subset of severe treatment refractory residents; c) compare an intensive treatment programme to a "standard" treatment programme; and d) find predictors of self or early discharge from the unit. METHOD: We compared treatment outcomes for (i) a minimum 12-week treatment (hereafter "standard") programme versus a 2-week intensive programme and (ii) for severe treatment refractory cases on the standard programme. We identified 472 residents with OCD admitted to the Anxiety Disorders Residential Unit at the Bethlem Royal Hospital between 2001 and 2012. Outcomes were measured with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Obsessive Compulsive Inventory (OCI), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) obtained throughout treatment and up to one year after discharge. RESULTS: Although residents had very severe OCD on admission, sequential assessment with the Y-BOCS, OCI, BAI and BDI demonstrated that scores on all outcome measures significantly decreased from pre to posttreatment and were generally maintained at follow-up. There was no significant difference between those on the standard or the 2-week intensive programme. Sixty-nine per cent of residents with OCD made significant improvements, with at least a 25% reduction on the Y-BOCS. There were predictors of self or early discharge but none for outcome on the Y-BOCS. CONCLUSIONS: The data support the principle of stepped care for severe OCD.

A new therapeutic community: development of a compassion-focussed and contextual behavioural environment.

Social relationships and communities provide the context and impetus for a range of psychological developments, from genetic expression to the development of core self-identities. This suggests a need to think about the therapeutic changes and processes that occur within a community context and how communities can enable therapeutic change. However, the 'therapeutic communities' that have developed since the Second World War have been under-researched. We suggest that the concept of community, as a change process, should be revisited within mainstream scientific research. This paper briefly reviews the historical development of therapeutic communities and critically evaluates their current theory, practice and outcomes in a systematic review. Attention is drawn to recent research on the nature of evolved emotion regulation systems, the way these are entrained by social relationships, the importance of affiliative emotions in the regulation of threat and the role of fear of affiliative emotions in psychopathology. We draw on concepts from compassion-focussed therapy, social learning theory and functional analytical psychotherapy to consider how members of a therapeutic community can be aware of each other's acts of courage and respond using compassion. Living in structured and affiliative-orientated communities that are guided by scientific models of affect and self-regulation offers potential therapeutic advantages over individual outpatient therapy for certain client groups. This conclusion should be investigated further. Key Practitioner Message Current therapeutic community practice is not sufficiently evidence based and may not be maximizing the potential therapeutic value of a community. Compassion-focussed therapy and social learning theory offer new approaches for a therapeutic environment, involving an understanding of the role, nature and complexities of compassionate and affiliative relationships from staff and members, behavioural change guided by learning theory, a clear formulation based on threat-derived safety strategies, goal setting and positive reinforcement.

Psychosexual outcome after labiaplasty: a prospective case-comparison study.

INTRODUCTION AND HYPOTHESIS: Our goal was to determine psychosexual outcome after labiaplasty in the long-term with specific measures of genital body image and sexual dysfunction. METHOD: We conducted a prospective study with a matched-comparison group of women not wanting labiaplasty. Forty-nine women were compared against a group of 39 women matched for age, sexual orientation, ethnicity, and marital status. The labiaplasty group was assessed before, 3 months after and between 11 and 42 months after surgery. The comparison group was assessed at two time points 3 months apart to control for the passage of time. The primary outcome measure was the Genital Appearance Satisfaction (GAS) scale. RESULTS: Of the 49 women receiving labiaplasty, 19 (38.8 %) were lost to follow-up but were reassessed clinically. Twenty-four of 25 (96 %) women in the labiaplasty group showed a reliable and clinically significant improvement on the GAS scale 3 months after the procedure; 21/23 (91.3 %) showed an improvement at the long-term follow-up. A large effect size was found for improvements on the GAS scale in the labiaplasty group. Small-effect sizes were found for improvements in sexual functioning. Nine women obtaining labiaplasty met diagnostic criteria for body dysmorphic disorder before the operation; eight lost that diagnosis at the 3-month follow-up; 26 % reported minor side effects. CONCLUSIONS: Labiaplasty is effective in improving genital appearance and sexual satisfaction, but larger studies are required to determine the prevalence of potential side effects.

Social connectedness, emotional regulation, and health behaviors as correlates of distress during lockdown for COVID-19: A diary study.

Mass lockdowns are a powerful infection-reduction strategy but are a significant stressor. This study aimed to explore whether various factors known to predict distress in normal contexts (e.g. social connectedness, emotional-regulation strategies, and health-related behaviors) are associated with daily distress under lockdown conditions. A time-based diary study evaluated how perceived social connectedness, health-promoting, and risk behaviors predicted within-person and between-person psychological distress. One hundred and nine adults completed surveys on these variables daily for 15 days while under stringent COVID-19 lockdown in Colombia. Emotional suppression and reappraisal were measured at the start of the study to explore whether they predicted distress. Distress was lower on the days that people experienced greater social connectedness (within-person analyses) but was not significantly predicted by between-participant differences in emotional regulation. Health-promoting behaviors such as exercising and meaningful activity were associated with lower distress, while watching COVID-19 news and eating high-calorie food were associated with higher distress. Looking at individual dynamics provides meaningful insights on daily behaviors associated with distress that might improve people's wellbeing during lockdown, such as social connectedness, meaningful activity, nutrition, exercise, and minimizing news exposure. Future research with alternative designs will enable causal conclusions to be drawn.

Physiological response to self-compassion versus relaxation in a clinical population.

BACKGROUND: Compassion-focused imagery (CFI) can be an effective emotion-regulation technique but can create threat-focused responses in some individuals. However, these findings have been based on tasks involving receiving compassion from others. AIMS: This study sought to compare responses CFI involving self-compassion to relaxation and a control task, and to see whether any threat-responses to self-compassion and relaxation decrease with practice. METHOD: 25 participants with depression/anxiety symptoms and high self-criticism and/or low self-compassion engaged in three tasks (control task, relaxation imagery, and CFI) at three or four separate testing sessions, every three days. Heart-rate variability (HRV) was used to explore group-level differences between tasks. Additionally, we identified how many individuals showed a clinically significant change in HRV in response to compassion (compared to baseline) and how many showed such a change during relaxation (compared to baseline). RESULTS: During session 1, more individuals had a clinically significant increase in HRV in response to CFI (56%) than in response to relaxation (44%), and fewer had a clinically significant decrease in HRV during CFI (16%) than during relaxation (28%). Comparing the group as a whole, no significant differences between tasks were seen. Repeated sessions led to fewer positive responses to CFI, perhaps reflecting habituation/boredom. CONCLUSIONS: These preliminary findings suggest that in high self-critics (those most likely to find self-compassion difficult), self-compassionate imagery is no more challenging than standard relaxation tasks. For both compassion and relaxation, some individuals respond positively and others negatively. For those who are not benefiting, practice alone is not sufficient to improve response. Effects may differ for other compassion tasks. TRIAL REGISTRATION: Trial number: NCT04647318.

Depression, Anxiety, and Posttraumatic Stress Disorder Following Intimate Partner Violence: The Role of Self-Criticism, Guilt, and Gender Beliefs.

Intimate partner violence (IPV) predicts anxiety, depression, and posttraumatic stress disorder (PTSD), yet the role of cognition in these pathways is poorly understood. This study explored whether self-criticism, guilt, and gender beliefs predicted psychological symptoms, using self-report data from 50 Colombian female IPV survivors with diverse socioeconomic statuses. Self-criticism and guilt were high and significantly associated with IPV. Self-criticism significantly predicted depression and PTSD, whilst only guilt predicted anxiety. Traditional gender role beliefs were associated with emotional abuse, but not with self-criticism, guilt, or symptoms. In conclusion, self-criticism and guilt are important treatment targets for female IPV survivors, regardless of gender beliefs.

Compassion-focused imagery reduces shame and is moderated by shame, self-reassurance and multisensory imagery vividness.

Compassion-focused imagery (CFI) is an emotion-regulation technique involving visualization of a person, animal or object offering one compassion, to generate feelings of safeness. It is proven to increase self-compassion and reduce negative affect. This study explores two hypotheses not previously investigated: i) which sensory modalities can stimulate compassionate affect; and ii) whether presentation of pictorial stimuli can enhance CFI. Additionally, we examine iii) whether CFI can reduce shame and iv) whether self-criticism inhibits CFI, since previous studies have involved small samples or methodological limitations. After completing measures of self-criticism, selfreassurance and imagery abilities in five sensory modalities, participants (n=160) were randomly assigned to look at compassionate images during CFI (visual input), compassionate images before CFI (priming), or abstract images (control). Participants trialled CFI then rated compassionate affect and completed open-response questions. Before and after CFI, participants recalled a shame-based memory and rated state shame. Correlational analyses explored whether self-criticism, self-reassurance, and multisensory imagery abilities moderated outcomes. CFI significantly reduced shame regarding a recalled memory, particularly for those high in shame. Compassionate affect was predicted by imagery vividness in visual and bodily-sensation modalities. Self-criticism predicted poorer CFI In multiple regressions, self-reassurance predicted poorer CFI outcomes but self-criticism did not. Between-group effects did not emerge. Qualitative data suggested that pictures helped some participants but hindered others. CFI is a promising technique for shame-prone clients, but may be challenging for those with low imagery abilities or unfamiliar with self-reassurance. Multiple senses should be engaged.

Development of a compassion-focused and contextual behavioural environment and validation of the Therapeutic Environment Scales (TESS).

Aims and method The aims of the study were to develop a scale sensitive enough to measure the interpersonal processes within a therapeutic environment, and to explore whether the new scale was sensitive enough to detect differences between settings, including a community based on compassionate mind and contextual behaviourism. The Therapeutic Environment Scales (TESS) were validated with 81 participants in three different settings: a specialist service for anxiety disorders, a specialist in-patient ward and a psychodynamic therapeutic community. Results TESS was found to be reliable and valid. Significant differences were seen between the services on the dimensions of compassion, belongingness, feeling safe, positive reinforcement of members' acts of courage, extinction and accommodation of unhelpful behaviours, inconsistency and high expressed emotion. These processes were over time associated with improved outcomes on a specialist service for anxiety disorders. Clinical implications The TESS offers a first step in exploring important interpersonal relationships in therapeutic environments and communities. An environment based on a compassionate mind and contextual behaviourism offers promise for the running of a therapeutic community.