Examining processes of change for acceptance and commitment therapy and cognitive behavioral therapy self-help books with depressed college students.

Given the prevalence of depression, it is worthwhile to consider a variety of treatment approaches to reach as many sufferers as possible, including highly accessible formats such as self-help books. Books based in acceptance and commitment therapy (ACT) and cognitive behavioral therapy (CBT) propose to treat depression through distinct processes of change, though the degree to which these treatments are distinguishable in this format is unclear. Furthermore, it is possible that some individuals may respond better to therapeutic processes from one approach over the other based on personal preferences. We tested the effects of ACT and CBT self-help books on processes of change in a sample of 139 depressed college students in which some participants were given a choice of treatment and others were randomized. Cognitive fusion, which improved better in the ACT group, was the only process of change that distinguished the two treatments. Additionally, early improvements in cognitive fusion were associated with less depression-related stigma at posttreatment. Lastly, randomization, instead of choosing a treatment, led to greater improvements in almost all processes of change. We discuss how these findings inform personalized care, tangible differences between ACT and CBT, and effective practices for treating depression at large scale.

Adding online storytelling-based acceptance and commitment therapy to antidepressant treatment for primary care patients: a randomized clinical trial.

Depression is most often treated in primary care, where the prevailing treatment is antidepressant medication. Primary care patients with depression are less likely to be exposed to psychosocial interventions, despite evidence suggesting many of these treatments are effective. An example is acceptance and commitment therapy (ACT), a behavioral treatment for depression with a growing evidence base. A self-guided ACT intervention with a peer narrative (i.e. storytelling) format was developed with the intention of creating a treatment option for primary care patients that was more accessible than traditional psychotherapy. Titled LifeStories, the online program features videos of real individuals sharing coping skills for depression based on lived experiences and key ACT principles. A total of 93 primary care patients taking antidepressants were randomized to either continued antidepressant treatment alone or antidepressant treatment plus LifeStories for 4 weeks. There were no differences over time on depression severity and psychological inflexibility. However, LifeStories led to greater improvements in quality of life and increased patients' interest in additional treatment compared to antidepressant medication alone.Clinical trial pre-registration: ClinicalTrials.gov (NCT04757961).

Self-compassion and body image inflexibility as mediators of outcomes in a residential eating disorder sample.

Eating disorders are serious mental health conditions that are accompanied by negative health outcomes, high mortality rates, impaired functioning, and comorbid mental health conditions. Despite many empirically supported interventions for eating disorders, it remains one of the most challenging mental disorders to treat, as individuals often struggle to maintain treatment gains. One method of improving our understanding of effective eating disorder treatment is to identify important processes of change to target during therapy. The aim of the current study was to test two candidate mediators of disordered eating symptom change during residential treatment: self-compassion and body image inflexibility. In the present study, women and adolescent girls (N = 132) completed a battery of measures, including eating disorder severity, self-compassion, and body image inflexibility, at admission to and discharge from a residential eating disorder facility. Our results indicated that changes in body image inflexibility and self-compassion, specifically self-judgment, were both mediators between ED symptom severity from pre- to post-treatment. These results have potential treatment implications, pointing to the possible importance of targeting body image inflexibility, self-judgment, and self-compassion while treating eating disorders.

Moderators and predictors in a parent hearing aid management eHealth program.

OBJECTIVE: Consistent hearing aid use is essential for spoken language development of children who are hard of hearing. A recent randomised controlled trial of an eHealth hearing aid management education program found the intervention increased knowledge, perceptions, confidence, and device monitoring among parents of young children. Yet, it is not known which variables can be a point of emphasis to improve treatment outcomes. The purpose of this study was to investigate potential moderators and predictors in the eHealth program. DESIGN: Randomised controlled trial. STUDY SAMPLE: Parents (N = 78) of children (42 months or younger) were randomised to the intervention or treatment-as-usual (TAU) group. RESULTS: Results revealed that high psychological inflexibility, low parent activation, and low hours of hearing aid use may moderate device monitoring frequency and knowledge; parents in the intervention improved over time compared to the TAU group. Psychological inflexibility and parent activation also predicted treatment outcomes. CONCLUSION: The findings suggest the need to address parent psychological inflexibility related to hearing loss management, parents' role in their child's hearing aid management, and reported hours of hearing aid use as part of hearing aid service delivery. Identification of barriers to hearing aid management can assist audiologists in adjusting support to improve outcomes.

Acceptance and Action Questionnaire-Adult Hearing Loss (AAQ-AHL): validation with hearing aid users.

OBJECTIVE: Individuals who are deaf or hard of hearing (DHH) may find adherence to their hearing devices difficult due to internal experiences related to their hearing loss such as sadness or frustration. The Acceptance and Action Questionnaire-Adult Hearing Loss (AAQ-AHL) is the only measure available to assess psychological inflexibility as it relates to hearing loss. The purpose of this study was to confirm the single latent structure of the AAQ-AHL (through confirmatory factory analysis) and test convergent and discriminant validity. DESIGN: Cross-sectional data was used to further validate the AAQ-AHL. STUDY SAMPLE: Participants were 146 adults who had diagnosed hearing loss and used a hearing aid. RESULTS: Results revealed the AAQ-AHL has a single latent structure, correlated to other similar constructs (psychological flexibility and hearing aid efficacy), and not correlated to unrelated constructs (hearing loss severity). These results suggest that the AAQ-AHL is a valid instrument to assess psychological flexibility as it relates to hearing aid use. CONCLUSION: Together, the findings imply the AAQ-AHL has strong psychometric properties and justification to use in a clinical setting.

A systematic review and meta-analysis of self-guided online acceptance and commitment therapy as a transdiagnostic self-help intervention.

Online Acceptance and Commitment Therapy (ACT) interventions use websites and smartphone apps to deliver ACT exercises and skills. The present meta-analysis provides a comprehensive review of online ACT self-help interventions, characterizing the programs that have been studied (e.g. platform, length, content) and analyzing their efficacy. A transdiagnostic approach was taken, including studies that addressed a range of targeted problems and populations. Multi-level meta-analyses were used to nest multiple measures of a single construct within their respective studies. A total of 53 randomized controlled trials were included (n = 10,730). Online ACT produced significantly greater outcomes than waitlist controls at post-treatment for anxiety, depression, quality of life, psychological flexibility, and all assessed outcomes (i.e. omnibus effect), which were generally maintained at follow-up. However, only psychological flexibility and all assessed outcomes at post-treatment were found to be significantly greater for online ACT when compared to active controls, with no significant follow-up effects. Overall, these results further clarify that ACT can be effectively delivered in an online format to target a wide range of mental health concerns, although it is less clear if and when online ACT is more efficacious than other online interventions.

Values engagement as a predictor of eating disorder severity in a residential sample of female adolescents with eating disorders.

Values are freely chosen life directions and/or qualities of being that can motivate behavior change. There is nascent support for the utility of values work as a part of the therapeutic process across treatments, particularly in third wave therapy approaches (e.g., acceptance and commitment therapy). However, therapeutic values work is underresearched in clinical samples of youth. The aim of the present study is to examine the role of the two distinct values processes (engagement and obstruction), body image inflexibility, alongside other common comorbid symptoms of eating disorders (anxiety, depression) in a sample of female adolescents with eating disorders attending a residential eating disorder treatment program. Participants (N = 75) were patients at a residential eating disorder treatment facility and completed a battery of measures at time of admission. Correlational analyses and multiple regression were performed. Results found correlations between eating disorder severity, values engagement, values obstruction, body image flexibility, anxiety, and depression in the expected directions. Regression results found body image inflexibility, progression towards values, and anxiety as significant predictors of eating disorder severity (adjusted R2 = .54). This study points to the importance of emphasizing values engagement in youth with eating disorders, highlighting a potential treatment target for future research.

Examining a mediation model of body image-related cognitive fusion, intuitive eating, and eating disorder symptom severity in a clinical sample.

PURPOSE: This study sought to explore the associations between Intuitive Eating (IE), eating disorder (ED) symptom severity, and body image-related cognitive fusion within a clinical sample. IE was also examined as a possible mediator in the relationship between body image-related fusion and ED symptoms. METHODS: This study includes cross-sectional analyses with data from 100 adult females and 75 adolescent females seeking residential treatment for an ED. Self-reported demographic information, ED symptoms, IE behaviors, and body image-related cognitive fusion were collected from participants within the first week of treatment following admission to the same residential ED treatment facility. RESULTS: ED symptom severity was significantly negatively associated with three of the four domains of IE; unconditional permission to eat, reliance on hunger and satiety cues, and body-food choice congruence. A significant mediational effect of IE on the relationship between body image-related fusion and ED symptoms through IE behaviors was observed (ß = 11.3, SE = 0.003, p < 0.001). This effect was only observed for the unconditional permission to eat (ß = 0.13, p = 0.003) and reliance on hunger and satiety cues (ß = 0.10, p = 0.005) domains of IE when the domains were subsequently analyzed individually. CONCLUSION: Unconditional permission to eat and reliance on hunger and satiety cues appear to be particularly influential domains of IE in the relationship between body image-related fusion and ED symptom severity. It is possible that changes in these IE domains may be mechanisms through which body image-related fusion influences ED symptoms. Future longitudinal research is needed to better understand the relationship between body image-related cognitive fusion and IE and the potential for targeting these constructs specifically in the context of ED treatment. LEVEL OF EVIDENCE: Level V, cross-sectional analysis from descriptive study.

Hearing care and management priority among parents of children with Down syndrome: a grounded theory.

OBJECTIVE: This study qualitatively explored the factors that influence how parents of children who are Deaf or hard-of-hearing with Down syndrome prioritise hearing care and management and developed an associated theory to explain that priority. DESIGN: Grounded theory was used for the purposes of this qualitative study. Data were collected using in-depth interviews which were analysed using a three-tiered qualitative coding process. STUDY SAMPLE: Eighteen mothers of children who are Deaf or hard-of-hearing with Down syndrome participated in this study. RESULTS: The higher the extent of engaged professional support, perception of benefit for child, parent activation, and family engagement, the higher the priority for hearing care and management will likely be among parents of children who are Deaf or hard-of-hearing with Down syndrome. CONCLUSIONS: Understanding how parents of children who are Deaf or hard-of-hearing with Down syndrome decide to prioritise hearing care and management has implications for how hearing health providers and others provide care to parents to enhance priority for hearing-related needs.

eHealth parent education for hearing aid management: a pilot randomized controlled trial.

OBJECTIVE: Parents frequently experience challenges implementing daily routines important for consistent hearing aid management. Education that supports parents in learning new information and gaining confidence is essential for intervention success. We conducted a pilot study to test an eHealth program to determine if we could implement the program with adherence and affect important behavioural outcomes compared to treatment as usual. DESIGN: Randomised controlled trial. STUDY SAMPLE: Parents of children birth to 42 months who use hearing aids. Eighty-two parents were randomly assigned to the intervention or treatment-as-usual group. Four parents assigned to the intervention group did not continue after baseline testing. RESULTS: The intervention was delivered successfully with low drop out (10%), high session completion (97%), and high program adherence. The intervention conditions showed significantly greater gains over time for knowledge, confidence, perceptions, and monitoring related to hearing aid management. Significant differences between groups were not observed for hearing aid use time. CONCLUSION: We found that we could successfully implement this eHealth program and that it benefitted the participants in terms of knowledge and confidence with skills important for hearing aid management. Future research is needed to determine how to roll programs like this out on a larger scale.

Evaluating the effects of guided coaching calls on engagement and outcomes for online acceptance and commitment therapy.

Previous research indicates mixed results for guided support with online interventions. The current secondary analysis evaluated the effects of phone coaching from a dismantling trial of online acceptance and commitment therapy (ACT) in a sample of 136 distressed college students randomized to one of three versions of an ACT website. Participants were randomized to receive email prompts alone (non-coaching condition) or email plus phone coaching (coaching condition). Results indicated no differences between the coaching and non-coaching conditions on program engagement, program satisfaction, mental health outcomes, and almost all psychological flexibility processes. However, participants in the coaching condition reported stronger pre- to posttreatment improvements in psychological inflexibility than the non-coaching condition. This effect was moderated by ACT component condition, with larger pre- to posttreatment effects from coaching on psychological inflexibility in the values/committed action condition and weaker improvements from coaching in the acceptance/defusion condition. Overall, results indicate online self-guided ACT interventions with email prompts are sufficient for addressing college student mental health and that phone coaching provided minimal additional benefit.

Is perfectionism always unhealthy? Examining the moderating effects of psychological flexibility and self-compassion.

OBJECTIVE: Perfectionism is generally associated with worse mental health outcomes, though evidence suggests elements of it may be helpful. In light of these findings, we examined whether psychological skills like psychological flexibility and self-compassion moderated the relationship between perfectionism and wellbeing (i.e., quality of life, symptom impairment, and psychological distress). METHODS: Undergraduate students (N = 677) completed self-report measures. RESULTS: A latent profile analysis identified three perfectionism groups (low, average, and high) based on four perfectionism subscales: concern over mistakes, need for approval, rumination, and striving for excellence. Generally, we found that psychological flexibility and/or self-compassion buffered the impact of average and high perfectionism on quality of life and symptom impairment. CONCLUSION: Our results support the utility of practicing psychological flexibility and/or self-compassion for people with average and high levels of perfectionism. Limitations include using a cross-sectional design and nonclinical sample.

Not just thinking, but believing: Obsessive beliefs and domains of cognitive fusion in the prediction of OCD symptom dimensions.

Cognitive fusion (CF) involves the tendency to "buy in" to thoughts and feelings and consists of three empirically established domains: somatic concerns, emotion regulation, and negative evaluation. CF is hypothesized to play a role in obsessive-compulsive disorder (OCD). The present study examined how well the CF domains, relative to traditional cognitive-behavioural constructs (i.e., obsessive beliefs such as inflated responsibility), predict OCD symptoms. Fifty-two treatment-seeking adults with OCD completed self-report measures of CF, obsessive beliefs, OCD symptoms, and general distress. Domains of CF were differentially associated with the responsibility for harm, symmetry, and unacceptable thoughts of OCD dimensions; yet after accounting for obsessive beliefs, only the negative evaluation domain of CF significantly predicted symmetry OCD symptoms. Obsessive beliefs significantly predicted all OCD dimensions except for contamination. These findings provide additional support for existing cognitive-behavioural models of OCD across symptom dimensions, with the exception of contamination symptoms, and suggest that the believability of thoughts and feelings about negative evaluation adds to the explanation of symmetry symptoms. Conceptual and treatment implications, study limitations, and future directions are discussed.

Measuring psychological inflexibility in adult and child hearing loss.

Objective: Hearing loss is a chronic condition that impacts functioning among individuals with hearing loss and caregivers of children with hearing loss. Even though treatments for hearing loss can alleviate functional impairment, psychological factors like psychological inflexibility may interfere with treatment engagement and adherence, undermining the benefits of treatment. Measuring psychological inflexibility may inform care providers' case conceptualisation, improving the quality and precision of audiological interventions. Thus, this study aimed to develop and validate measures of psychological inflexibility in hearing loss for adults and caregivers of children with hearing loss. Design: Participants were invited to complete an online survey. Study samples: Our sample comprised adults with hearing loss (N = 264) and primary caregivers of children with hearing loss (N = 275). Results: The final versions of Acceptance and Action Questionnaire-Adult Hearing Loss (AAQ-AHL) and Acceptance and Action Questionnaire-Management of Child Hearing Loss (AAQ-MCHL) showed good to excellent internal reliability and concurrent and discriminant validity. Conclusion: Although the AAQ-AHL and AAQ-MCHL showed acceptable psychometric properties, more tests are needed to further validate these measures and verify their utility in research and clinical settings.

Increasing body image flexibility in a residential eating disorder facility: Correlates with symptom improvement.

OBJECTIVE: The purpose of this study was to examine the effects of changes in body image psychological flexibility over the course of treatment on various outcome variables. METHOD: Participants included 103 female, residential patients diagnosed with an eating disorder. Pretreatment and posttreatment data were collected that examined body image psychological flexibility, general psychological flexibility, symptom severity, and other outcome variables. RESULTS: Changes in body image psychological flexibility significantly predicted changes in all outcome measures except for obsessive-compulsive symptoms after controlling for body mass index, depression, and anxiety. Additionally, these results were maintained after controlling for general psychological flexibility, contributing to the incremental validity of the BI-AAQ. DISCUSSION: This study suggests that changes in body image psychological flexibility meaningfully predict changes in various treatment outcomes of interest, including eating disorder risk, quality of life, and general mental health. Findings indicate that body image psychological flexibility might be a viable target for eating disorder treatment.

Audiologists' communication behaviour during hearing device management appointments.

OBJECTIVE: The aim of this exploratory study was to describe audiologist communication behaviours during appointments for hearing device monitoring and management before and after participation in counselling skills training. DESIGN: The study used a longitudinal design with three assessment points over 6 months. STUDY SAMPLE: The sample included 10 audiologists and audiology graduate students interacting in a professional setting with their clients. RESULTS: Audiologists reported improvement in their counselling skills from pre-training to follow-up, which was consistent with objective findings that audiologist relative speaking time decreased from pre-training to post-training as well as from pre-training to follow-up. Observer-rated scores of participants' counselling skills; however, yielded no significant differences across time. CONCLUSIONS: Some improvement was noted in audiologists' counselling behaviour following a 1-day communication skills workshop and continued learning support. It is evident; however, that further training, such as increased training and performance feedback, is needed to maintain and enhance audiologist progress in the various aspects of counselling.

Pediatric Hearing Aid Management: Parent-Reported Needs for Learning Support.

OBJECTIVES: The aim of this study was to investigate parent learning and support needs related to hearing aid management for young children, and factors that influence parent-reported hours of hearing aid use. DESIGN: A cross-sectional survey design was used to collect survey data in seven states. The child's primary caregiver completed a demographic form, a questionnaire to explore parent learning and support needs as well as their challenges with hearing aid use, and the patient health questionnaire to identify symptoms of depression. Three hundred and eighteen parents completed the questionnaires. RESULTS: Responses were analyzed for 318 parents of children (M = 23.15 months; SD = 10.43; range: 3 to 51) who had been wearing hearing aids (M = 15.52; SD = 10.11; range: <1 to 50 months). Even though the majority of parents reported receiving the educational support queried, approximately one-third wanted more information on a variety of topics such as loaner hearing aids, what their child can/cannot hear, financial assistance, how to meet other parents, how to do basic hearing aid maintenance, and how to keep the hearing aids on their child. The most frequently reported challenges that interfered with hearing aid use (rated often or always) were child activities, child not wanting to wear the hearing aids, and fear of losing or damaging the hearing aids. Forty-two percent of parents reported that, on good days, their child used hearing aids all waking hours. Multiple regression was used to compare the effect on parent-reported typical hours of hearing aid use based on good days for the variables of (1) presence of depressive symptoms for the parent, (2) child age, (3) family income, (4) primary caregiver education level, (5) presence of additional disabilities for the child, (6) degree of hearing loss, and (7) length of time since the child was fitted with hearing aids. There were statistically significantly fewer hours of reported hearing aid use when parents reported mild to severe symptoms of depression, lower income, less education level, and when children had mild hearing loss or additional disabilities. CONCLUSION: Although parents reported overall that their needs for hearing aid education and support had generally been met, there were important suggestions for how audiologists and other service providers could better meet parent needs. Hearing aid use for young children was variable and influenced by a variety of factors. Understanding parent experiences and challenges can help audiologists more effectively focus support. Audiologists are more likely to meet the needs of families if they take care to provide access to thorough and comprehensive education and ongoing support that is tailored to address the unique needs of individual families.

Effectiveness and clinical response rates of a residential eating disorders facility.

The purpose of this study was to determine the effectiveness of a residential treatment program for adults and adolescents with eating disorders across a wide spectrum of measures. Data on body mass, eating disorder severity, depression, anxiety, and two measures of quality of life were collected on 139 consecutively admitted adolescents and 111 adults at a residential treatment program (N = 250). The same measures were completed at post-treatment. Group level analyses showed that adults and adolescents improved on all measures analyzed. Only 1.7% of adolescents and 2.3% of adults were below a Body Mass Index of 18.5 at discharge. Positive results across diagnoses and ages are reported for three subscales of the Eating Disorder Inventory-3, with clinical response rates reported. Using clinical responder analyses, it was found that for all individuals struggling with secondary issues, 74.7% were responders on the Beck Depression Inventory-II, 41.0% on the Beck Anxiety Inventory, 63.5% on a measure of quality of life, and 95.8% were responders on the physical subscale and 72.6% on the mental subscale of the SF-36-v2. This study suggests that residential treatment for eating disorders is effective at the group level, and it was effective for the majority of individuals within the group.

Pediatric hearing aid use: parent-reported challenges.

OBJECTIVES: The aim of this study was to investigate parent-reported challenges related to hearing aid management and parental psychosocial characteristics during the first 3 years of the child's life. DESIGN: Using a cross-sectional survey design, surveys were distributed to parents of children with hearing loss via state Early Intervention programs in Utah and Indiana. Packets contained one family demographic form and two sets of three questionnaires to obtain responses from mothers and fathers separately: the Parent Hearing Aid Management Inventory explored parent access to information, parent confidence in performing skills, expectations, communication with the audiologist, and hearing aid use challenges. The Acceptance and Action Questionnaire measured psychological flexibility, experiential avoidance, and internal thought processes that can affect problem-solving ability and decrease an individual's ability to take value-based actions. The Patient Health Questionnaire identified symptoms of depression. Thirty-seven families completed questionnaires (35 mothers and 20 fathers). RESULTS: Most responses were parents of toddlers (M = 22 months) who had been wearing binaural hearing aids for an average of 15 months. Both mothers and fathers reported that even though the amount of information they received was overwhelming, most (84%) preferred to have all the information at the beginning, rather than to receive it over an extended time period. Parents reported an array of challenges related to hearing aid management, with the majority related to daily management, hearing aid use, and emotional adjustment. Sixty-six percent of parents reported an audiologist taught them how to complete a listening check using a stethoscope, however, only one-third reported doing a daily hearing aid listening check. Both mothers and fathers reported a wide range of variability in their confidence in performing activities related to hearing aid management, and most reported minimal confidence in their ability to troubleshoot hearing aid problems. More than half of the parents reported child behavior and activities, such as playing outside, as a major hearing aid use challenge. Parents reported hearing aids were worn all waking hours by 35% of children and less than 5 hr/day by 31%. Almost half of the parents (47%) did not feel that they had enough time to talk about their emotions when speaking with their audiologist(s), 69% reported the audiologist did not help them know what to expect related to emotions about their child's hearing loss, and 22% reported symptoms of depression. CONCLUSIONS: Parents reported an array of challenges, even after their child had been wearing hearing aids for a prolonged time, revealing critical implications for how to provide audiological care. Audiologists have an important role in partnering with parents to identify and jointly problem-solving challenges related to their child's hearing aid use. Supporting parents includes not only addressing technical aspects of hearing testing and hearing aid function but also addressing parent thoughts, feelings, and emotions.

Examining DSM criteria for trichotillomania in a dimensional framework: implications for DSM-5 and diagnostic practice.

BACKGROUND: Diagnosis of trichotillomania (TTM) requires meeting several criteria that aim to embody the core pathology of the disorder. These criteria are traditionally interpreted monothetically, in that they are all equally necessary for diagnosis. Alternatively, a dimensional conceptualization of psychopathology allows for examination of the relatedness of each criterion to the TTM latent continuum. OBJECTIVES: First, to examine the ability of recently removed criteria (B and C) to identify the latent dimensions of TTM psychopathology, such that they discriminate between individuals with low and high degrees of hair pulling severity. Second, to determine the impact of removing criteria B and C on the information content of remaining diagnostic criteria. Third, to determine the psychometric properties of remaining TTM diagnostic criteria that remain largely unchanged in DSM-5; that is, whether they measure distinct or overlapping levels of TTM psychopathology. Fourth, to determine whether information content derived from diagnostic criteria aid in the prediction of disease trajectory (i.e., can relapse propensity be predicted from criteria endorsement patterns). METHOD: Statistics derived from item response theory were used to examine diagnostic criteria endorsement in 91 adults with TTM who underwent psychotherapy. RESULTS: The removal of two criteria in DSM-5 and psychometric validity of remaining criteria was supported. Additionally, individual trait parameters were used to predict treatment progress, uncovering predictive power where none previously existed. CONCLUSIONS: Diagnostic criteria for TTM should be examined in dimensional models, which allow for nuanced and sensitive measurement of core symptomology in treatment contexts.