Therapist perceptions of experiential training for exposure therapy.

BACKGROUND: Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS: This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD: Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS: Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION: Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

Intolerance of Uncertainty and Parental Accommodation: Promising Targets for Personalized Intervention for Youth Anxiety.

PURPOSE OF REVIEW: After reviewing predictors of differential outcomes of cognitive behavioral therapy (CBT) for pediatric anxiety, we identify and discuss recent evidence for the role of (a) intolerance of uncertainty (IU) and (b) parental accommodation as meaningful targets for personalized intervention. RECENT FINDINGS: Few studies to date have identified promising, theory-driven predictors of differential CBT outcomes. Recent findings suggest that increased IU and high levels of parental accommodation are associated with a poorer response to CBT. Several adaptations of CBT and new interventions targeting either IU or parental accommodation have been developed and found to be efficacious in preliminary studies. IU and parental accommodation are promising constructs for personalizing intervention, both in the identification of who will respond to treatment and in the development of targeted intervention. We recommend that future work test if individuals high in IU and/or parental accommodation will respond more optimally to treatments that specifically target these constructs. The results of this future work may help to move the field closer to personalized intervention.

Multi-informant Expectancies and Treatment Outcomes for Anxiety in Youth.

Expectancies for a favorable treatment outcome have been associated with actual favorable outcomes but have been understudied in youth with anxiety. The current study applied structural equation modeling in a sample of anxious youth (N = 488; 7-17 years, M = 10.69, SD = 2.80) to examine whether a multi-informant latent expectancies factor, indicated by youth, parent, and therapist reports, predicted a latent posttreatment anxiety factor, controlling for a latent pretreatment anxiety factor. Both anxiety latent factors were indicated by youth, parent, and independent evaluator (IE) reports. Analyses also examined whether treatment condition (cognitive behavioral therapy, sertraline, combination, pill placebo) moderated the association between expectancies and outcome, and whether this association differed across development. Findings indicated that informant reports loaded similarly onto the latent factors. Results also demonstrated that treatment expectancies were positively associated with outcomes, and that this relationship held across treatment type and age group. Treatment implications and future research directions are discussed.

Attention, rumination and depression in youth with negative inferential styles: A prospective study.

BACKGROUND: Negative inferential style, rumination and attention are cognitive vulnerabilities implicated in depression that first emerge in childhood and adolescence. METHODS: The current study used a prospective longitudinal design to examine whether rumination mediates the relationship between attention (selective attention, sustained attention, attentional switching, and divided attention) and depression (depressive symptoms and depressive episode onset) conditional on negative inferential style. A diverse community sample of adolescents (n = 364) completed semi-structured diagnostic interviews, behavioral measures of attention, and self-report measures of rumination, negative inferential style, and depression annually for three consecutive years. RESULTS: Rumination mediated the relationship between strong sustained attention and both depressive symptoms and disorder onset conditional on negative inferential style. Specifically, adolescents high in negative inferential style with strong sustained attention were more likely to experience increased subsequent rumination that, in turn, led to increased depressive symptoms and episode onset. In contrast to study hypotheses, there were no significant effects for models that included selective attention, attentional switching, or divided attention. LIMITATIONS: Significant effects were relatively small, and therefore, should be interpreted with caution and require replication. We were unable to control for intelligence, and as a result, stronger sustained attention may be indicative of higher intelligence. CONCLUSIONS: Stronger sustained attention in early adolescence compared to peers may facilitate rumination on negative self-evaluation and subsequent depression. Use of non-emotion-relevant stimuli to assess attention may account for the lack of findings for selective attention, attentional switching, or divided attention. Implications and directions for future research are discussed.

A Qualitative Examination of a School-Based Implementation of Computer-Assisted Cognitive-Behavioral Therapy for Child Anxiety.

Mental health treatment in schools has the potential to improve youth treatment access. However, school-specific barriers can make implementing evidence-based interventions difficult. Task-shifting (i.e., training lay staff to implement interventions) and computer-assisted interventions may mitigate these barriers. This paper reports on a qualitative examination of facilitators and barriers of a school-based implementation of a computer-assisted intervention for anxious youth (Camp Cope-A-Lot; CCAL). Participants (N = 45) included school staff in first through fourth grades. Providers attended a training in CCAL and received weekly, hour-long group consultation calls for three months. In the second year, the sustainability of CCAL use was assessed. Qualitative interviews were conducted after the first year (initial implementation) and second year (sustainability). Interviews were analyzed using the Consolidated Framework for Implementation Research domains to classify themes. Although participants reported that CCAL included useful skills, they expressed concerns about recommended session length (45 minutes) and frequency (weekly). Time burden of consultation calls was also a barrier. School staff facilitated implementation by enabling flexible scheduling for youth to be able to participate in the CCAL program. However, the sustainability of the program was limited due to competing school/time demands. Results suggest that even with computer assisted programs, there is a need to tailor interventions and implementation efforts to account for the time restrictions experienced by school-based service providers. Optimal fit between the intervention and specific school is important to maintain the potential benefits of computer-assisted treatments delivered by lay service providers in schools.

Intolerance of uncertainty in youth: Psychometrics of the Intolerance of Uncertainty Index-A for Children.

Intolerance of uncertainty (IU) is a cognitive vulnerability for pathological anxiety. The current study adapted the Intolerance of Uncertainty Index-A for Children (IUI-A-C), and created a single-item Intolerance of Uncertainty Clinician-Rated Index (IUCR), both of which assess a youth's general inability to endure uncertainty. Psychometric properties of these two measures were evaluated. Participants were 146 youth aged 7-17 years seeking treatment for anxiety. The IUI-A-C evidenced individual item performance (i.e., correlations between each item and the total remainder score > .40, ps <.001), internal consistency, convergent validity with the IUCR and self-report measures of anxiety and functional impairment, divergent validity with ADHD severity, and retest reliability with a mean interval of over four weeks. The IUCR also evidenced convergent validity with the IUI-A-C and self-report measures of anxiety and functional impairment and divergent validity with ADHD severity. The IUI-A-C predicted composite principal diagnosis severity but did not predict composite GAD diagnosis severity. The IUI-A-C and IUCR have utility as measures of IU in youth. The role of IU in specific anxiety disorders and future research are discussed.

Training with tarantulas: A randomized feasibility and acceptability study using experiential learning to enhance exposure therapy training.

BACKGROUND: Although exposure is a key evidence-based intervention for anxiety, it is infrequently used in clinical settings. This study employed a novel training strategy, experiential learning, to improve exposure implementation. This study aimed to assess the feasibility and acceptability of experiential training and preliminary training effectiveness. METHODS: Participants were 28 therapists who were randomized to (a) training-as-usual or (b) experiential training (training-as-usual plus a one-session treatment for fear of spiders). Workshops lasted one day and were followed by three months of weekly consultation. RESULTS: Experiential training was viewed as feasible and acceptable. Participants, including those who were fearful of spiders, had a positive response to the training and reported it to be useful. There was a significant increase in the number of exposures used by therapists receiving experiential training compared to training-as-usual at 1-month follow-up. CONCLUSIONS: A one-day training resulted in significant improvements in knowledge, attitudes toward exposure, and self-efficacy in using exposure. Preliminary findings suggest that experiential training resulted in greater use of exposure post-training compared to training-as-usual. Results provide evidence for the feasibility and acceptability of experiential training as a strategy to increase the use of evidence-based interventions.

Translating CBM-I Into Real-World Settings: Augmenting a CBT-Based Psychiatric Hospital Program.

Cognitive bias modification for interpretation (CBM-I) is an appealing augmentation to cognitive-behavioral therapy (CBT) because it targets cognitive bias efficiently via computerized training. Few studies have tested the combination of CBM-I and CBT, and none have translated lab-based CBM-I protocols to an acute psychiatric setting. The present study describes the development and implementation of CBM-I as an augmentation to a CBT-based partial hospital. We developed a transdiagnostic CBM-I based on the word-sentence association paradigm (WSAP), which reinforces individuals for endorsing benign interpretations and rejecting negative interpretations of ambiguous sentences. Over two iterations of development, we randomly assigned patients (N = 127; M age = 34.21; 58% female, 40% male, 2% nonbinary) to either CBM-I or a control group (Phase 1: neutral WSAP task; Phase 2: treatment as usual). CBM-I comprised daily sessions (10 minutes) completed during program hours, and number of sessions varied naturalistically according to patient length of stay. Primary outcomes included feasibility, acceptability, and target engagement (interpretation bias). CBM-I was feasible and acceptable to acute psychiatric patients, and successfully shifted interpretation for novel stimuli. Patient feedback suggested that participants viewed CBM-I as bolstering their primary CBT-based care. Exploratory analyses examining clinical benefit revealed a small between-group effect on anxiety severity (d = 0.378), but no group differences on depression outcomes (d = 0.008). Findings indicate that CBM-I is a feasible and acceptable augmentation to CBT-based partial hospital care. Future studies are warranted to determine who is most likely to benefit from this low-intensity approach.

But what will the results be?: Learning to tolerate uncertainty is associated with treatment-produced gains.

The current study examined the association between changes in intolerance of uncertainty (IU) and treatment outcomes for anxious youth. Participants were youth ages 7 to 17 who received cognitive behavioral therapy for anxiety (N = 73). Youth and their primary caregivers completed a diagnostic interview and self- and parent-report measures at pre- and post-treatment, including the Intolerance of Uncertainty Scale for Children (IUS-C/P; Przeworski, 2006), the Coping Questionnaire (CQ-C/P; Kendall, 1994) and the Multidimensional Anxiety Scale for Children (MASC-C/P; March et al., 1997). Hierarchical regression analyses evaluated the role of change in IU (the IUS-C/P) in predicting changes in functional impairment, coping efficacy, and anxiety severity post-treatment, controlling for demographic variables (age and gender), and baseline levels of IU, anxiety severity, functional impairment, and coping efficacy. Results demonstrated that treatment was associated with improvements across child-, parent- and clinician-report, and decreased IU from pre- to post-treatment was associated with (a) decreased functional impairment, (b) increased coping efficacy and (c) decreased anxiety severity. The findings indicate that a greater reduction in IU over treatment is associated with better outcomes in children and adolescents with anxiety across informants, suggesting the possibility that an increased focus on IU during treatment for youth anxiety may improve treatment outcomes. Future research should assess the causality of this relationship.

Characteristics of interpretation bias and relationship with suicidality in a psychiatric hospital sample.

BACKGROUND: Interpretation bias, the tendency to interpret ambiguous situations negatively (or to lack a positive bias), is a cognitive vulnerability associated with psychopathology. However, there is a lack of research characterizing this bias in psychiatric samples, including whether it is also a risk factor for suicidality. This study characterized interpretation bias in a psychiatric sample at risk for suicide and examined the relationship between interpretation bias and suicidality cross-sectionally and prospectively. METHODS: Patients (N=65) attending a partial hospital program completed the Word-Sentence Association Paradigm (WSAP), which results in four variables reflecting different types of interpretation bias: endorsement rates and reaction time bias scores for negative and benign interpretations. We conducted logistic regression models to predict high suicidality (ideation, plans, attempts, etc. assessed via a structured interview at admission) and suicidal ideation (assessed via self-report at admission and discharge). RESULTS: Logistic regression models predicting suicide outcomes upon admission and discharge indicated that benign interpretation endorsement was the most robust predictor of suicidality concurrently and prospectively, controlling for baseline suicidal ideation. LIMITATIONS: Lack of gold standard self-report suicide assessment. Unable to assess additional constructs such as hopelessness or perfectionism, which may better elucidate how lacking a benign bias influences suicidality. Modest sample size. CONCLUSIONS: A lower endorsement of positive interpretations was the strongest predictor of prospective suicidal ideation, even after controlling for baseline suicidal ideation. Future research should examine how targeting interpretation bias influences suicidality.

Adaptation of a paradigm for examining the development of fear beliefs through the verbal information pathway in preschool-age children.

Verbal threat information has been shown to induce fear beliefs in school-age children (i.e. 6-12 years; for a review see Muris & Field, 2010). The current study adapted an existing paradigm (Field & Lawson, 2003) to examine the impact of verbal threat information on self-report and behavioral measures of fear in preschool-age children. Thirty children (aged 3-5) were provided with threat, positive, or no information about three novel Australian marsupials. There was a significant increase in fear belief for the animal associated with threat information compared to the animal associated with positive or no information. Verbal threat information did not impact behavioral avoidance in the complete sample; however, findings from an exploratory subgroup analysis excluding three-year-olds indicated that children demonstrated significant behavioral avoidance for the threat condition compared to the positive condition. These findings provide additional support for Rachman's theory of fear acquisition (1977, 1991) and suggest this paradigm may be used to examine the age at which verbal threat information becomes a relevant mode of fear acquisition for young children.

A Randomized Survey of the Public's Expectancies and Willingness to Participate in Clinical Trials of Antidepressants Versus Psychotherapy for Depression.

BACKGROUND: Expectancies and treatment preferences are known to affect the outcomes of patients enrolled in clinical trials for depression, but there is little research on their influence when the public is considering participation in these trials. METHOD: We conducted an online survey (May 2013) in which participants (N = 615) were randomly assigned to read hypothetical descriptions of clinical trials for depression based on 1 of the following study designs: medication versus placebo, medication versus medication, psychotherapy versus placebo, or psychotherapy versus psychotherapy. Afterward, individuals rated willingness to participate in the trial, logic and credibility of the treatments, and expected success and improvement in symptoms. RESULTS: There were no differences in expectancies for ratings of credibility and logic or success and improvement among clinical trial designs. However, self-reported willingness to participate in the study was rated significantly higher in the 2 psychotherapy trial designs (active-comparator and placebo-controlled) compared with the active-comparator medication design (P < .05). Psychiatric treatment history, general treatment preferences, and depression severity were positively correlated with willingness to participate primarily in the active-comparator medication design. CONCLUSIONS: Consistent with the broader treatment preference literature, individuals reported a greater willingness to participate in psychotherapy compared with antidepressant studies. Thus, people's perceptions of different treatments are likely to influence not only the outcomes of clinical trials for depression but also decisions to participate in these trials in the first place.

Positive beliefs about mental illness: Associations with sex, age, diagnosis, and clinical outcomes.

BACKGROUND: Beliefs about mental illness affect how individuals cope with their symptoms. Positive beliefs about mental illness (PBMI) refer to perceptions of positive attributes individuals may identify in their illness, such as beneficial consequences, enhanced creativity or cognition, or growth through adversity. METHODS: The present study developed and tested a brief measure of PBMI in 332 adults presenting for partial hospitalization with a variety of acute psychiatric conditions. RESULTS: Results indicated that older individuals and women had lower levels of PBMI than others, while individuals with bipolar disorder had higher levels of PBMI than others. PBMI significantly increased over the course of brief standard treatment. Baseline levels of PBMI, as well as changes in PBMI over the course of treatment, were associated with clinical outcomes including, but not limited to, depression and well-being. A diagnosis of bipolar disorder moderated the relationship between PBMI and only one clinical outcome, emotional lability. Increases in PBMI during treatment were associated with reduced emotional lability only in participants without bipolar disorder. LIMITATIONS: Our findings are limited by the naturalistic study design. In addition, the lack of ethnoracial diversity in our sample limits the generalization of results. CONCLUSIONS: Our results suggest that PBMI are a distinct set of beliefs that meaningfully relate to demographic characteristics, diagnostic characteristics, and clinical outcomes. Future research should examine the mechanisms through which PBMI and outcomes are related, as well as determine whether interventions designed to address PBMI (and perhaps tailored for different diagnostic groups) have clinical utility.

Psychometric properties of the anxiety sensitivity index-3 in an acute and heterogeneous treatment sample.

Anxiety sensitivity (AS) is associated with various forms of psychopathology. The most common measure of AS is the anxiety sensitivity index-3 (ASI-3). The current study examined the psychometric properties and factor structure of the ASI-3 in an acute and comorbid population seeking treatment for a broad range of psychopathology (N=382). Results confirmed a bi-factor structure and suggested that the ASI-3 demonstrates adequate psychometric properties in a transdiagnostic sample. The ASI-3 also showed adequate sensitivity to change over the course of partial hospital treatment. Findings regarding associations between specific anxiety disorders and subscales of the ASI-3 are discussed. Overall, the current results support the use of the ASI-3 to assess AS in heterogeneous treatment-seeking samples. This work is of particular utility for researchers examining the concept of AS transdiagnostically.