Physiological activation and co-activation in an imagery-based treatment for test anxiety.

Objective: The effectiveness of Imagery Rescripting (IR) has been demonstrated in the treatment of various psychological disorders, but the mechanisms underlying it remain unclear. While current investigations predominantly refer to memory processes, physiological processes have received less attention. The main aim of this study is to test whether client physiological activation (i.e., arousal) and client-therapist physiological activation (i.e., synchrony) during IR segments predicted improvement on next-session outcomes and overall treatment response, and to compare these to the role of physiological (co)-activation during traditional cognitive-behavioral (CB) segments. Methods: The results are based on 177 therapy sessions from an imagery-based treatment for test anxiety with 60 clients. Client and therapist electrodermal activity was continuously monitored, next-session outcome was assessed with the Outcome Rating Scale and treatment outcome was assessed using the Test Anxiety Inventory. Results: Hierarchical linear models demonstrated that average physiological synchrony during IR segments (but not during CB ones) was significantly associated with higher well-being at both the session and the overall treatment levels. Clients' physiological arousal in either IR or CB segments was not predictive of either outcome. Conclusion: These results provide initial evidence for the idea that physiological synchrony might be an important underlying mechanism in IR.

Dynamic prediction of psychological treatment outcomes: development and validation of a prediction model using routinely collected symptom data.

BACKGROUND: Common mental disorders can be effectively treated with psychotherapy, but some patients do not respond well and require timely identification to prevent treatment failure. We aimed to develop and validate a dynamic model to predict psychological treatment outcomes, and to compare the model with currently used methods, including expected treatment response models and machine learning models. METHODS: In this prediction model development and validation study, we obtained data from two UK studies including patients who had accessed therapy via Improving Access to Psychological Therapies (IAPT) services managed by ten UK National Health Service (NHS) Trusts between March, 2012, and June, 2018, to predict treatment outcomes. In study 1, we used data on patient-reported depression (Patient Health Questionnaire 9 [PHQ-9]) and anxiety (Generalised Anxiety Disorder 7 [GAD-7]) symptom measures obtained on a session-by-session basis (Leeds Community Healthcare NHS Trust dataset; n=2317) to train the Oracle dynamic prediction model using iterative logistic regression analysis. The outcome of interest was reliable and clinically significant improvement in depression (PHQ-9) and anxiety (GAD-7) symptoms. The predictive accuracy of the model was assessed in an external test sample (Cumbria Northumberland Tyne and Wear NHS Foundation Trust dataset; n=2036) using the area under the curve (AUC), positive predictive values (PPVs), and negative predictive values (NPVs). In study 2, we retrained the Oracle algorithm using a multiservice sample (South West Yorkshire Partnership NHS Foundation Trust, North East London NHS Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, and Cambridgeshire and Peterborough NHS Foundation Trust; n=42 992) and compared its performance with an expected treatment response model and five machine learning models (Bayesian updating algorithm, elastic net regularisation, extreme gradient boosting, support vector machine, and neural networks based on a multilayer perceptron algorithm) in an external test sample (Whittington Health NHS Trust; Barnet Enfield and Haringey Mental Health Trust; Pennine Care NHS Foundation Trust; and Humber NHS Foundation Trust; n=30 026). FINDINGS: The Oracle algorithm trained using iterative logistic regressions generalised well to external test samples, explaining up to 47·3% of variability in treatment outcomes. Prediction accuracy was modest at session one (AUC 0·59 [95% CI 0·55-0·62], PPV 0·63, NPV 0·61), but improved over time, reaching high prediction accuracy (AUC 0·81 [0·77-0·86], PPV 0·79, NPV 0·69) as early as session seven. The performance of the Oracle model was similar to complex (eg, including patient profiling variables) and computationally intensive machine learning models (eg, neural networks based on a multilayer perceptron algorithm, extreme gradient boosting). Furthermore, the predictive accuracy of a more simple dynamic algorithm including only baseline and index-session scores was comparable to more complex algorithms that included additional predictors modelling sample-level and individual-level variability. Overall, the Oracle algorithm significantly outperformed the expected treatment response model (mean AUC 0·80 vs 0·70, p<0·0001]). INTERPRETATION: Dynamic prediction models using sparse and readily available symptom measures are capable of predicting psychotherapy outcomes with high accuracy. FUNDING: University of Sheffield.

Physiological synchrony and therapeutic alliance in an imagery-based treatment.

Client-therapist synchrony in various channels (e.g., self-reported affect or physical movement) has been shown as a key process in the construction and development of therapeutic alliance. However, psychophysiological synchrony between clients and therapists has been understudied, with the few extant studies typically relying on single-session data, and no studies examining it within the context of emotion-focused techniques. The main aim of the current paper is to examine the role of client-therapist physiological synchrony during segments of one emotion-focused technique-namely, imagery (IM) work-in predicting therapeutic alliance, and to compare it to the role of synchrony during segments of more traditional cognitive-behavioral (CB) techniques. We conducted an open-trial study in which 31 clients with test anxiety received a 6-session protocol-based treatment. Both clients' and therapists' electrodermal activity (EDA) were continuously assessed during sessions. The physiological measures for 5 sessions each (N = 128) were used to compute client-therapist synchrony in IM and CB segments. Therapeutic alliance was assessed using the Session Alliance Inventory. Client-therapist dyads' synchrony during IM and CB segments was, on average, greater than chance. Synchrony varied mostly at the session (vs. the dyad) level. Multilevel analyses revealed that the synchrony within IM segments (but not within CB segments) was significantly associated with the therapeutic bond aspect (but not the task/goal aspects) of alliance. Physiological synchrony during emotion-focused IM is tied to the bond component of the therapeutic alliance at the session level. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Imagery-based treatment for test anxiety: A multiple-baseline open trial.

BACKGROUND: Many students are affected by test anxiety (TA), which involves considerable distress and can lead to reduced performance. Despite its prevalence, TA has been under-studied; specifically, few effective and brief interventions have been identified to date. In our work, we explore the adaptation of imagery, an emotion-focused treatment technique used widely in the treatment of other anxiety disorders, for addressing TA. METHODS: In a two-site concurrent multiple-baseline pilot study (n = 31), we examined the effectiveness of a targeted six-session protocol developed for the treatment of TA, which integrates traditional cognitive behavioral techniques with imagery work. RESULTS: The protocol was well-accepted by clients. We found that students' test anxiety levels did not drop between the recruitment and pre-intervention assessments, but did drop significantly from recruitment or baseline to the delayed follow-up (Cohen's d = 0.75 and 0.84, respectively). We also found evidence for session-level processes tying the quality of the imagery work with session efficacy. LIMITATIONS: The study involved a relatively small sample size, leading to weaker power to detect treatment effects. Moreover, some clients did not have any exams scheduled before the delayed follow-up assessment. Due to the scheduling intensity of the sessions, some clients had insufficient time to implement or practice skills and to complete tasks discussed in the sessions. CONCLUSIONS: This study provides preliminary evidence for the utility of integrating imagery work with traditional cognitive-behavioral techniques for treating test anxiety.

Mindfulness and progressive muscle relaxation as standardized session-introduction in individual therapy: A randomized controlled trial.

OBJECTIVE: There is scarce research on the effects of mindfulness in individual therapy. As many practitioners integrate mindfulness exercises into individual therapy, empirical evidence is of high clinical relevance. METHOD: We investigated the effects of a session-introducing intervention with mindfulness elements (SIIME) in a randomized, controlled design. The effects of SIIME on therapeutic alliance and symptomatic outcome were compared with progressive muscle relaxation (PMR) and treatment-as-usual (TAU) control conditions. The sample comprised 162 patients with anxiety and depression. RESULTS: Multilevel modeling revealed a significant symptom reduction and significant increase of alliance over the course of therapy. There were no significant time-condition interactions on outcome and alliance, indicating the comparable efficiency of all three treatment conditions. CONCLUSIONS: We found no advantage of SIIME versus PMR and TAU. Add-on mindfulness might not improve individual therapy related to alliance and outcome.

Individual treatment selection for patients with posttraumatic stress disorder.

BACKGROUND: Trauma-focused cognitive behavioral therapy (Tf-CBT) and eye movement desensitization and reprocessing (EMDR) are two highly effective treatment options for posttraumatic stress disorder (PTSD). Yet, on an individual level, PTSD patients vary substantially in treatment response. The aim of the paper is to test the application of a treatment selection method based on a personalized advantage index (PAI). METHOD: The study used clinical data for patients accessing treatment for PTSD in a primary care mental health service in the north of England. PTSD patients received either EMDR (N = 75) or Tf-CBT (N = 242). The Patient Health Questionnaire (PHQ-9) was used as an outcome measure for depressive symptoms associated with PTSD. Variables predicting differential treatment response were identified using an automated variable selection approach (genetic algorithm) and afterwards included in regression models, allowing the calculation of each patient's PAI. RESULTS: Age, employment status, gender, and functional impairment were identified as relevant variables for Tf-CBT. For EMDR, baseline depressive symptoms as well as prescribed antidepressant medication were selected as predictor variables. Fifty-six percent of the patients (n = 125) had a PAI equal or higher than one standard deviation. From those patients, 62 (50%) did not receive their model-predicted treatment and could have benefited from a treatment assignment based on the PAI. CONCLUSIONS: Using a PAI-based algorithm has the potential to improve clinical decision making and to enhance individual patient outcomes, although further replication is necessary before such an approach can be implemented in prospective studies.

[Imagery Rescripting and Psychophysical Relations Based on the ImRs-Therapy Concept Used for Test Anxiety: Review and First Experience]. / Imagery Rescripting und psychophysiologische Zusammenhänge anhand eines ImRs-Behandlungskonzepts für Prüfungsangst: Überblick und erste Erfahrungen.

Imagery Rescripting (ImRs) is an emotion-focused treatment technique, which was developed for persons suffering from traumatic experiences. ImRs includes imaginary exposure and rescripting alongside cognitive re-structuring. The principle of ImRs is based on the activation of emotions and the structuring of dysfunctional affective-cognitive schemata. ImRs is an effective treatment for PTSD and could be adapted to suit other psychological disorders. The current state of research focuses primarily on the wide range of uses. To date, physiological processes during the imagery rescripting have not been explored. Because of this, together with the cooperation of colleagues at Bar-Ilan University in Israel, we have conducted a pilot study to investigate psychophysiological patterns during ImRS sessions. Specifically, we examine the effectiveness of a targeted 6-session protocol developed for the treatment of test anxiety on a student sample, during which we monitor the sympathetic response of both clients and therapists. First feedback from the participants supports the power of imagery.

The Process-Outcome Mindfulness Effects in Trainees (PrOMET) study: protocol of a pragmatic randomized controlled trial.

BACKGROUND: Mindfulness has its origins in an Eastern Buddhist tradition that is over 2500 years old and can be defined as a specific form of attention that is non-judgmental, purposeful, and focused on the present moment. It has been well established in cognitive-behavior therapy in the last decades, while it has been investigated in manualized group settings such as mindfulness-based stress reduction and mindfulness-based cognitive therapy. However, there is scarce research evidence on the effects of mindfulness as a treatment element in individual therapy. Consequently, the demand to investigate mindfulness under effectiveness conditions in trainee therapists has been highlighted. METHODS/DESIGN: To fill in this research gap, we designed the PrOMET Study. In our study, we will investigate the effects of brief, audiotape-presented, session-introducing interventions with mindfulness elements conducted by trainee therapists and their patients at the beginning of individual therapy sessions in a prospective, randomized, controlled design under naturalistic conditions with a total of 30 trainee therapists and 150 patients with depression and anxiety disorders in a large outpatient training center. We hypothesize that the primary outcomes of the session-introducing intervention with mindfulness elements will be positive effects on therapeutic alliance (Working Alliance Inventory) and general clinical symptomatology (Brief Symptom Checklist) in contrast to the session-introducing progressive muscle relaxation and treatment-as-usual control conditions. Treatment duration is 25 therapy sessions. Therapeutic alliance will be assessed on a session-to-session basis. Clinical symptomatology will be assessed at baseline, session 5, 15 and 25. We will conduct multilevel modeling to address the nested data structure. The secondary outcome measures include depression, anxiety, interpersonal functioning, mindful awareness, and mindfulness during the sessions. DISCUSSION: The study results could provide important practical implications because they could inform ideas on how to improve the clinical training of psychotherapists that could be implemented very easily; this is because there is no need for complex infrastructures or additional time concerning these brief session-introducing interventions with mindfulness elements that are directly implemented in the treatment sessions. TRIAL REGISTRATION: From ClinicalTrials.gov, Identifier: NCT02270073 (registered October 6, 2014).

Feedback and therapist effects in the context of treatment outcome and treatment length.

OBJECTIVE: This study estimates feedback and therapist effects and tests the predictive value of therapists' and patient attitudes toward psychometric feedback for treatment outcome and length. METHODS: Data of 349 outpatients and 44 therapists in private practices were used. Separate multilevel analyses were conducted to estimate predictors and feedback and therapist effects. RESULTS: Around 5.88% of the variability in treatment outcome and 8.89% in treatment length were attributed to therapists. There was no relationship between the average effectiveness of therapists and the average length of their treatments. Initial impairment, early alliance, number of diagnoses, feedback as well as therapists' and patients' attitudes toward feedback were significant predictors of treatment outcome. Treatments tended to be longer for patients with a higher number of approved sessions by the insurance company, with higher levels of interpersonal distress at intake, and for those who developed negatively (negative feedback) over the course of their treatment. CONCLUSIONS: Therapist effects on treatment outcome and treatment length in routine care seem to be relevant predictors in the context of feedback studies. Therapists' attitudes toward and use of feedback as well as patients' attitudes toward feedback should be further investigated in future research on psychometric feedback.

Beyond words: sensory properties of depressive thoughts.

Verbal thoughts (such as negative cognitions) and sensory phenomena (such as visual mental imagery) are usually conceptualised as distinct mental experiences. The present study examined to what extent depressive thoughts are accompanied by sensory experiences and how this is associated with symptom severity, insight of illness and quality of life. A large sample of mildly to moderately depressed patients (N = 356) was recruited from multiple sources and asked about sensory properties of their depressive thoughts in an online study. Diagnostic status and symptom severity were established over a telephone interview with trained raters. Sensory properties of negative thoughts were reported by 56.5% of the sample (i.e., sensation in at least one sensory modality). The highest prevalence was seen for bodily (39.6%) followed by auditory (30.6%) and visual (27.2%) sensations. Patients reporting sensory properties of thoughts showed more severe psychopathological symptoms than those who did not. The degree of perceptuality was marginally associated with quality of life. The findings support the notion that depressive thoughts are not only verbal but commonly accompanied by sensory experiences. The perceptuality of depressive thoughts and the resulting sense of authenticity may contribute to the emotional impact and pervasiveness of such thoughts, making them difficult to dismiss for their holder.