Do patients internalize the positive regard they are offered? A dyadic test of a Rogerian condition.

OBJECTIVE: Positive regard (PR) reflects a therapist's unconditional prizing of their patient, which meta-analytically correlates positively with patient improvement. However, most research has been limited to single-participant ratings of PR at a specific time, which neglects the dyadic and dynamic nature of PR (i.e., fundamental to benefitting from therapist-offered PR is that a patient internalizes it). Testing this premise, we hypothesized that therapist-offered PR at one session would predict patient-felt PR at a subsequent session (two sessions later), which would in turn predict the patient's next-session outcome (within-patient mediation). METHOD: Eighty-four patients with generalized anxiety disorder received cognitive-behavioral therapy with or without motivational interviewing. Therapists and patients provided postsession ratings of their offered and felt PR, respectively, at odd-numbered sessions throughout treatment. Patients rated their worry following each even-numbered session. We used multilevel structural equation modeling to test our hypothesis. We explored whether treatment condition moderated the mediational path. RESULTS: As predicted, when a therapist regarded their patient more than usual following one session, the patient felt more regarded than usual. In turn, this internalized regard was negatively associated with worry. Treatment condition did not moderate this path. DISCUSSION: Results support internalized positive regard as a treatment-common, ameliorative relationship process.

Therapist-Level Moderators of Patient-Therapist Match Effectiveness in Community Psychotherapy.

Based on patient-reported outcomes data analyzed at the provider level, there is evidence that psychotherapists can possess effectiveness strengths and weaknesses when treating patients with different presenting concerns. These within-therapist differences hold promise for personalizing care by prospectively matching patients to therapists' historical effectiveness strengths. In a double-masked randomized controlled trial (RCT; NCT02990000), such matching outperformed pragmatically determined usual case assignment-which leaves personalized, measurement-based matching to chance-in naturalistic outpatient psychotherapy (Constantino et al., JAMA Psychiatry 78:960-969, 2021). Demonstrating that personalization can be even more precise, some research has demonstrated that the strength of this positive match effect was moderated by certain patient characteristics. Notably, though, it could also be that matching is especially important for some therapists to achieve more effective outcomes. Examining this novel question, the present study drew on the Constantino et al. (JAMA Psychiatry 78:960-969, 2021) trial data to explore three therapist-level moderators of matching: (a) effectiveness "spread" (i.e., greater performance variability across patients' presenting problem domains), (b) overestimation of their measurement-based and problem-specific effectiveness, and (c) the frequency with which they use patient-reported routine outcomes monitoring in their practice. Patients were 206 adults, randomized to the match or control condition, treated by 40 therapists who were crossed over conditions. The therapist variables were assessed at the trial's baseline and patients' symptomatic/functional impairment and global distress were assessed regularly up to 16 weeks of treatment. Hierarchical linear models revealed that only therapist effectiveness spread significantly moderated the match effect for the global distress outcome; for therapists with more spread, the match effect was more pronounced, whereas the match effect was minimal for therapists with less effectiveness spread. Notably, two therapist-level covariates unexpectedly emerged as significant moderators for the symptomatic/functional impairment outcome; for clinicians who consistently treated patients with higher versus lower average severity levels and who relatedly treated a higher proportion of patients with primary presenting problems of substance misuse or violence, the beneficial match effect was even stronger. Thus, measurement-based matching may be especially potent for therapists with more variable effectiveness across problem domains, and who consistently treat patients with more severe presenting concerns or with particular primary problems, which provides further precision in conceptualizing personalized care.

Therapist verification of patient self-concepts as a responsive precondition for early alliance development and subsequent introject change.

OBJECTIVE: Social psychological research has indicated that people strive for self-consistent feedback and interactions, even if negative, to preserve the epistemic security of knowing themselves. Without such self-verification, any interpersonal exchange may become frustrated, anxiety-riddled, and at risk for deterioration. Thus, it may be important for therapists to meet patients' self-verification needs as a responsive precondition for early alliance establishment and development. We tested this hypothesis with patients receiving cognitive behavioral therapy for generalized anxiety disorder-a condition that may render one's self-verification needs especially strong. We also tested the hypothesis that better early alliance quality would relate to subsequent adaptive changes in and posttreatment level of patients' self-concepts. METHOD: Eighty-four patients rated their self-concepts at baseline and across treatment and follow-up, their postsession recollection of their therapist's interpersonal behavior toward them during session 2, and their experience of alliance quality rated after sessions 3-6. RESULTS: As predicted, the more therapists verified at session 2 a patient's baseline self-concepts (which trended toward disaffiliative and overcontrolling, on average), the more positively that patient perceived their next-session alliance. Moreover, better session 3 alliance related to more adaptive affiliative and autonomy-granting self-concepts at posttreatment. CONCLUSION: Results are discussed within a therapist responsiveness framework.

A Qualitative Analysis of Stakeholder Attitudes Regarding Personalized Provider Selection and Patient-Therapist Matching.

This study explored mental health care patients and therapists' perspectives on using therapists' measurement-based and problem-specific effectiveness data to inform case assignments - a type of treatment personalization that has been shown to outperform non-measurement-based case assignment as usual (Constantino et al., 2021). We conducted semi-structured qualitative interviews with 8 patients (75% women; M age = 33.75 years) and 8 therapists (75% women; M age = 47.50 years). The interview protocols were unique to stakeholder group. Recorded responses were transcribed and qualitatively analyzed by four judges using a blend of consensual qualitative research and grounded theory methods. Derived patient domains included preferred characteristics of a provider, and experiences and suggestions regarding provider selection. Within the domains, most patients expressed an interest in accessing more specific provider information online. Additionally, most patients indicated that both provider outcome track records and personal preference information (e.g., therapist characteristics) should be considered in the therapist selection process. All patients endorsed being comfortable with having the ability to select a provider based on a list of empirically well-matched recommendations. Derived therapist domains included using routine outcomes monitoring for patient-provider matching, referral source and direct patient use of preferred provider lists, and improvements to the provider selection process. Within the domains, all therapists remarked that outcome data would be useful for matching patients to providers; however, most also indicated that outcome data should not be the only factor used in provider selection. All therapists expressed a willingness to be included in preferred provider lists that incorporate track record data. Overall, both patients and therapists held generally positive views toward using therapist effectiveness data to help personalize mental health care. Yet, both stakeholder groups acknowledged that other personalization factors should be considered alongside these data. Based on these results, our team is in the process of implementing patient-therapist match strategies in larger and more diverse mental health care contexts.

Therapist perceptions of their own measurement-based, problem-specific effectiveness.

OBJECTIVE: Patient-reported outcomes data reveal differences both in therapists' global effectiveness across their average patient (between-therapist effect) and in treating different problems within their caseload (within-therapist effects). Yet, it is unclear how accurately therapists perceive their own measurement-based, problem-specific effectiveness and whether such self-perceptions predict global between-therapist performance differences. We explored these questions in naturalistic psychotherapy. METHOD: For 50 therapists, we drew on data from a mean of 27 past patients (total N = 1,363) who completed a multidimensional outcome measure-Treatment Outcome Package (TOP)-at pre- and posttreatment. For each of 12 outcome domains (e.g., depression, anxiety), TOP data classified therapists as historically "effective," "neutral," or "ineffective." Unaware of their data-driven classifications, therapists rated their perceived effectiveness for each domain. We conducted chi-square analyses to determine whether therapists predicted their own measurement-based effectiveness classifications to a level greater than chance. We then used multilevel modeling to test whether therapists' problem-specific perceptions predicted global between-therapist performance differences. RESULTS: For all but one outcome domain, therapists were no better than chance at predicting their measurement-based effectiveness classification. Additionally, controlling for patient baseline impairment, therapists who consistently overestimated their problem-specific effectiveness had patients who reported worse global outcomes than patients whose therapist more accurately estimated their effectiveness. Conversely, therapists who underestimated their problem-specific effectiveness had patients who reported better outcomes than patients whose therapist over- or accurately estimated their effectiveness. CONCLUSIONS: Therapist humility may differentiate the most from least globally effective therapists, and this virtue should be cultivated in clinical trainings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Participant factors as correlates of patients' psychotherapy outcome expectation: A meta-analytic and box-count review.

OBJECTIVE: More positive pre- or early therapy patient outcome expectation (OE) has consistently correlated with better treatment outcomes. Thus, it is important to identify factors that contribute to patients' OE, which can inform therapist responsivity to such risk or facilitative markers. With growing research on OE correlates-centered primarily on patient characteristics/treatment factors and, to a lesser extent, therapist factors-a comprehensive synthesis is warranted to elucidate replicated and mixed associations and stimulate further research. Accordingly, we set a pragmatic cutoff of k ≥ 5 for meaningful empirical aggregation of participant factor-OE associations; otherwise, we conducted box counts. METHOD: We searched for articles published through March 2022 that included a clinical sample, a measure of patient's pre- or early treatment OE, and an explicit test of the factor-OE association. RESULTS: Patient problem severity, problem chronicity, education, age, and quality of life were meta-analyzed. Greater severity correlated with lower/less optimistic OE (r = -0.13, p < .001) and higher QOL correlated with higher/more optimistic OE (r = 0.18, p < .001). Box counts revealed that few variables had consistent associations with OE. CONCLUSIONS: Some factors can help forecast patient OE, though additional research is needed to enhance confidence and clinical meaning.

Replicating patient-level moderators of CBT and IPT's comparative efficacy for depression.

Although evidence-based psychotherapies, such as cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT), produce comparable average outcomes, it is plausible that some patients who possess one or more specific characteristics may respond better to one over the other. Addressing this what works best for whom question, researchers have tested the moderating influence of patient characteristics on comparative treatment effects (viz. aptitude-treatment interactions [ATIs]). However, few ATIs have emerged or replicated, thereby providing little treatment-selection guidance. Informed by a systematic review of patient ATIs in trials that compared CBT versus IPT for depression (Bernecker et al., 2017), this study aimed to replicate (a) significant ATIs previously established in a single study; and (b) significant ATIs previously examined twice, with only one study demonstrating a moderating effect. Data derived from a trial in which adult outpatients with major depression were randomly assigned to 16 weeks of CBT (n = 41) or IPT (n = 39). Patient characteristics were measured at baseline, and patients rated their depression throughout treatment. Multilevel models revealed one ATI replication; for patients with more self-sacrificing interpersonal problems, CBT outperformed IPT; the reverse was true for patients with fewer such problems. Other moderators either failed to replicate or directionally contradicted prior research. Results help inform optimal treatment matching for some patients, which reflects a type of psychotherapy personalization. However, they also highlight limitations of traditional ATI research and suggest that different methods are needed to inform responsive personalization efforts more expansively and reliably. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Developing an Assessment of Contraceptive Preferences in Botswana: Piloting a Novel Approach Using Best-Worst Scaling of Attributes.

Introduction: To develop an attribute-based method for assessing patient contraceptive preferences in Botswana and pilot its use to explore the relationship between patient contraceptive preferences and the contraceptive methods provided or recommended to patients by clinicians. Methods: A list of contraceptive attributes was developed with input from patients, clinicians, and other stakeholders. We assessed patient preferences for attributes of contraceptives using a discrete choice "best-worst scaling" approach and a multi-attribute decision-making method that linked patient attribute preferences to actual contraceptive method characteristics. Attribute-based patient method preferences and clinician recommendations were compared in 100 women seeking contraceptive services, and 19 clinicians who provided their care. For 41 of the patients, the short-term reliability of their preference scores was also examined. Results: For 57 patients who wanted more children in the future, the degree of concordance between patients and clinicians was 7% when comparing the top attribute-based contraceptive preference for each woman with the clinician-provided/recommended method. When the top two model-based preferred contraceptive methods were considered, concordance was 28%. For 43 women who did not want more children, concordance was 0% when using the patient's model-based "most-preferred" method, and 14% when considering the top two methods. Assessment of the short-term reliability of preference scores yielded an intraclass correlation coefficient of 0.93. Conclusions: A best-worst scaling assessment of attributes of contraceptives was designed and piloted in Botswana as a Contraceptive Preference Assessment Tool. The preference assessment was found to have high short-term reliability, which supports its potential use as a measurement tool. There was very low concordance between women's attribute-based contraceptive preferences and their clinician's provision/recommendations of contraceptive methods. Using such a preference assessment tool could encourage greater patient involvement and more tailored discussion in contraceptive consultations.

Patient-therapist expectancy convergence and outcome in naturalistic psychotherapy.

Research on close relationships demonstrates that dyadic convergence, or two people becoming more similar in their experiences and/or beliefs over time, is commonplace and adaptive. As psychotherapy involves a close relationship, patient-therapist convergence processes may influence treatment-specific outcomes. Although prior research supports that patients and therapists tend to converge on their alliance perspectives over time, which associates with subsequent patient improvement, no research has similarly examined belief convergence during therapy. Accordingly, this study focused on patient-therapist convergence in their outcome expectations (OE), a belief variable associated with patient improvement when measured from individual participant perspectives. We predicted both that significant OE convergence would occur and relate to better posttreatment outcome. Data derived from a trial of naturalistic psychotherapy. Patients and therapists repeatedly rated their respective OE through treatment, and patients rated their symptom/functional outcomes at posttreatment. For dyads with the requisite OE data (N = 154), we tested our questions using multilevel structural equation modeling. Counter to our hypotheses, there was no discernable OE convergence pattern over treatment (γ100 = 0.01, SE = 0.03, p = .690) and OE convergence was unrelated to outcome at the between-dyad level (γ020 = 2.37, SE = 10.28, p = .818). However, on its own, higher early patient OE was significantly associated with better outcome at the between-dyad level (γ050 = -0.04, SE = 0.01, p = .007). Results suggest that OE may be more of a facilitative patient versus relational process factor. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association between therapist attunement to patient outcome expectation and worry reduction in two therapies for generalized anxiety disorder.

Patients' higher psychotherapy outcome expectation (OE) correlates with improvement. Thus, it seems important that therapists attune to this belief, both in the moment and over time, to capitalize on its value when higher or respond to its potential risk when lower. Conceptually, attunement can have different guises, including the extent to which therapists (a) accurately estimate their patients' momentary OE level (low directional discrepancy), (b) become more accurate in estimating OE over time (convergence), (c) accurately track shifts in their patients' OE (temporal congruence), and (d) become more temporally congruent over time (alignment). To date, though, little is known empirically about therapist attunement to patient OE. Thus, we examined the presence of attunement indices and their relation to posttreatment outcome. Data derived from a randomized trial that compared cognitive-behavioral therapy (CBT; n = 43) to CBT plus motivational interviewing (n = 42) for patients with generalized anxiety disorder. After each session, patients rated their OE, and therapists estimated their patients' OE. Patients rated worry at baseline and posttreatment. Dyadic multilevel modeling revealed that across both treatments, therapists were directionally discrepant in that they underestimated patients' OE (p < .001), which did not change over time (no average convergence/divergence pattern; p = .43). Additionally, therapists exhibited temporal congruence with patients' OE (p < .001) and became more aligned with this rating over time (p = .008). Only greater OE convergence, when it occurred, predicted lower worry (p = .04). A therapist's increasingly accurate empathy about their patients' OE may be therapeutic. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Revived call for consensus in the future of psychotherapy.

The emblem of success in psychotherapy research and practice has long been innovation. Although such ingenuity is commendable, it has nonetheless perpetuated fragmentation across the field. At least four decades ago, it was suggested that achieving consensus on what constitutes psychotherapy's theoretical, empirical, and practical 'core' might allow the discipline to evolve beyond its siloed state, as is reflective of mature science. Yet, division remains the rule versus exception, owing in large part to power struggles among disparate schools of therapy and quarrels over whether theory-specific or theory-common factors most account for therapeutic change. We outline here a vision for psychotherapy's future that is defined by consensus rather than disintegration. Namely, we reiterate the need for the field to invest in clinical strategies that transcend ostensibly incompatible theoretical models. We also argue that psychotherapy research should build on the growing evidence for such clinical strategies in an effort to establish core, evidence-based principles of therapeutic change. We then discuss how establishing consensus will require reconciliation among the mounting evidence for flexible, principle-informed practice with the current realities of training, dissemination, and implementation paradigms. Finally, we articulate ways in which practicing clinicians will serve a vital role in carrying out, and amending as needed, actionable efforts toward psychotherapy consensus.

Indirect effect of patient outcome expectation on improvement through alliance quality: A meta-analysis.

Objective: A meta-analysis revealed a positive correlation between patients' optimistic baseline, or early treatment, outcome expectation (OE) and posttreatment improvement (Constantino, Vîsla, et al., [2018]. A meta-analysis of the association between patients' early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485. https://doi.org/10.1037/pst0000169). However, little is known about mechanisms through which OE operates. Increasingly, several individual studies have pointed to higher therapeutic alliance quality as a promising mediator (candidate mechanism) of the positive OE-improvement link. In this study, we conducted the first meta-analysis of this indirect effect, hypothesizing that alliance would partially mediate the OE-outcome link.Method: We included published articles involving a clinical sample; therapist-led treatment of at least 3 sessions; pre- or early treatment patient OE measures; during-treatment patient-rated alliance measures; posttreatment outcome measures; and statistical tests of mediation. This meta-analysis included 10 independent samples and over 1,000 patients.Results: As expected, better alliance quality partially mediated the association between more optimistic OE and improvement; that is, although both were significant, a multivariate analysis revealed that the direct effect was significantly lower than the total effect (standardized difference = -.12, p < .001, 95% CI [-.20, -.05]). Publication bias was low, as was heterogeneity except for the alliance-outcome path.Conclusions: Better alliance may be one process that helps transmit the therapeutic influence of early patient OE.

Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation.

Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.

Psychiatry Outpatients' Willingness to Share Social Media Posts and Smartphone Data for Research and Clinical Purposes: Survey Study.

BACKGROUND: Psychiatry research has begun to leverage data collected from patients' social media and smartphone use. However, information regarding the feasibility of utilizing such data in an outpatient setting and the acceptability of such data in research and practice is limited. OBJECTIVE: This study aimed at understanding the outpatients' willingness to have information from their social media posts and their smartphones used for clinical or research purposes. METHODS: In this survey study, we surveyed patients (N=238) in an outpatient clinic waiting room. Willingness to share social media and passive smartphone data was summarized for the sample as a whole and broken down by sex, age, and race. RESULTS: Most patients who had a social media account and who were receiving talk therapy treatment (74.4%, 99/133) indicated that they would be willing to share their social media posts with their therapists. The percentage of patients willing to share passive smartphone data with researchers varied from 40.8% (82/201) to 60.7% (122/201) depending on the parameter, with sleep duration being the parameter with the highest percentage of patients willing to share. A total of 30.4% of patients indicated that media stories of social media privacy breaches made them more hesitant about sharing passive smartphone data with researchers. Sex and race were associated with willingness to share smartphone data, with men and whites being the most willing to share. CONCLUSIONS: Our results indicate that most patients in a psychiatric outpatient setting would share social media and passive smartphone data and that further research elucidating patterns of willingness to share passive data is needed.

Predictors of treatment attendance in cognitive and dynamic therapies for major depressive disorder delivered in a community mental health setting.

OBJECTIVE: Our goal was to evaluate treatment attendance patterns, including both treatment completion and premature termination from treatment, for 2 evidence-based psychotherapies for major depressive disorder (MDD) delivered in a community mental health setting. We explored rates of premature termination across the course of treatment as well as the factors that predicted and moderated premature termination and treatment completion. METHOD: This investigation included 237 patients with MDD who participated in a noninferiority trial comparing short-term dynamic psychotherapy (DT) to cognitive therapy (CT). Patients in both conditions were offered 16 sessions of treatment and had up to 5 months to complete treatment. All patients completed an extensive self-report battery at treatment baseline as well as measures of the therapeutic alliance and opinions about treatment following Session 2. RESULTS: Premature termination from both treatments was high with 27% of patients discontinuing treatment very early after only an intake session or a single treatment session. Patients in CT were significantly more likely to terminate treatment prematurely, χ²(3) = 14.35, p = .002. Baseline physical health functioning, subthreshold psychotic symptoms, Session 2 ratings of agreement on tasks, and Session 2 ratings of treatment sensibility all independently predicted premature termination of services. Trauma history significantly moderated very early termination of treatment, χ²(3) = 10.26, p = .017, with patients with high trauma histories more likely to complete DT but terminate prematurely from CT. CONCLUSIONS: Very early termination from services was higher in CT compared with DT. Including techniques to improve engagement in both therapies and matching patients to treatment based on predictors/moderators may be effective ways to optimize treatment engagement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Trust and respect in the patient-clinician relationship: preliminary development of a new scale.

BACKGROUND: Trust and respect may be an important component of client-provider relationships. This study aimed to develop and report preliminary psychometric analyses of a new brief measure to evaluate a patient's level of trust and respect for their clinician. The scale was designed to be applicable in multiple healthcare contexts, with a particular focus on mental healthcare. METHODS: Adult patients completed the study survey in an academic outpatient psychiatric clinic waiting room. Classical and Item Response Theory (IRT) analyses were utilized to examine the adequacy of scale items. Validity was examined in relation to the patient-therapist alliance and to willingness to share private information (social media content) with one's clinician. RESULTS: Beginning with 10 items, a final 8-item version of the measure was created with an internal consistency reliability of .91. Principal components analysis indicated that the scale was best viewed as capturing one overall dimension. A Graded Response Model IRT model indicated that all items contributed information on the latent dimension, and all item curves were not flat at any region. The correlation of the trust/respect total score with the alliance was .53 when respect-related items were deleted from the alliance score. The trust/respect scale was significantly associated with patient willingness to share social media posts with their clinician but the alliance was not. CONCLUSIONS: The brief measure of patient trust and respect towards their clinician was unidimensional, showed good internal consistency, and was not redundant with existing measures of the alliance. The scale has the potential to be used in a wide variety of healthcare settings.

Symptoms of anhedonia, not depression, predict the outcome of treatment of cocaine dependence.

The purpose of this paper is to reanalyze data from two studies to determine if anhedonia specifically, rather than depression overall, predicts treatment outcome for patients with cocaine use disorders. Measures of baseline anhedonia symptoms were created using anhedonia items from the Beck Depression Inventory (BDI) to re-examine National Institute on Drug Abuse Cocaine Collaborative Treatment study data (Crits-Christoph et al., 1999) and the contingency management group from the McKay et al. (2010) trial. Baseline anhedonia was used to predict cocaine abstinence rates across the treatment period in both studies. Anhedonia was a significant predictor of cocaine abstinence, even when overall depression scores excluding anhedonia were included in the models. The development of treatments to target individuals with cocaine use disorder who have symptoms of anhedonia has the potential to improve overall outcomes for those with this disorder.

Is attention enhanced following performance errors? Testing the adaptive control hypothesis.

The present study tested whether people adaptively sharpen attentional focus following performance mistakes, as predicted by current theories of cognitive control. Participants completed a reverse Stroop task in which target stimuli were preceded by an informative spatial cue. Cue validity and Stroop interference effects on performance were robust, but neither effect was altered by commission of an error on the prior trial, as predicted by the adaptive control model. Likewise, a prior error did not enhance cue-evoked spatial asymmetries in EEG, nor did it enhance validity effects on neural responses evoked by targets. Instead, errors were followed by poorer overall performance and generalized arousal, as measured by generally suppressed EEG alpha power in postresponse and cue-to-target intervals following errors compared to correct responses. Results support an alternative theory that post-error changes in neural activity and performance reflect arousal, orienting, or cognitive bottlenecking rather than adaptive control of attention.