The Conditional Effects of Savoring on the Relationship between Minority Stress and Alcohol Misuse in an LGBTQIA + Sample.

Background: Alcohol-related difficulties are a significant public health concern in lesbian, gay, bisexual, transgender, questioning, intersex, asexual, and people with other sexual orientations and forms of gender identity (LGBTQIA+) communities. Considering these concerns, there is a strong push to develop affirming and strength-based prevention efforts. Unfortunately, such efforts are undermined by the lack of protective LGBTQIA + models for alcohol misuse. To this end, the purpose of the current study was to evaluate whether savoring, the ability to create, maintain, and prolong positive emotions, meets basic criteria for a protective factor for alcohol misuse in a sample of LGBTQIA + adults. Methods: The sample was comprised of 226 LGBTQIA + adults who completed an online survey. Results: Results indicated that savoring was inversely related to alcohol misuse. In addition, the relationship between minority stress and alcohol misuse varied as a function of savoring; at high levels of savoring (a score of 136.63 on the Savoring Beliefs Inventory), the relationship between minority stress and alcohol misuse was non-significant. Conclusions: In combination, these findings offer preliminary support for savoring as a protective factor for alcohol misuse among different LGBTQIA + communities. However, longitudinal and experimental research is needed to solidify the role of savoring in minimizing alcohol-related problems in this population.

A Randomized Controlled Trial of Brief Skills Training in Affective and Interpersonal Regulation (STAIR) for Veterans in Primary Care.

This randomized controlled trial assessed the efficacy of a five-session version of Skills Training in Affective and Interpersonal Regulation (STAIR) among veterans obtaining treatment in primary care. Veterans who screened positive for either posttraumatic stress disorder (PTSD) or depression (N = 26) were enrolled and randomized into either five-session STAIR or treatment as usual (TAU). Assessments of PTSD symptoms (PTSD Checklist for DSM-5; PCL-5), depression (Beck Depression Inventory-II; BDI-II), emotion regulation (Difficulties in Emotion Regulation Scale; DERS), and social engagement difficulties (World Health Organization Disability Assessment 2.0; WHODAS-2) were assessed at pretreatment, posttreatment, and 3-month follow-up assessments. Participants assigned to the five-session STAIR condition reported significant improvements on all measures, whereas those assigned to TAU showed no change. Group × Treatment interactions were significant for all outcomes, and effect sizes for the interactions ranged from moderate to large, Hedge's gs = 0.81 for the PCL-5, 1.15 for the BDI-II, 0.75 for the DERS, and 0.81 for the WHODAS-2. The results indicate that five-session STAIR, a brief, skills-focused treatment, may be effective in reducing a range of symptoms and in improving social functioning among veterans treated in primary care settings.

STAIR Group Treatment for Veterans with PTSD: Efficacy and Impact of Gender on Outcome.

Introduction: Group Skills Training in Affective and Interpersonal Regulation (STAIR) is an evidence-based, manualized treatment for individuals with post-traumatic stress symptoms, that focuses on improving functioning through mood management (e.g., emotion regulation) and relationship skills development. To date, no study has evaluated the potential benefit of group STAIR among Veterans. Feasibility of delivering STAIR in a mixed-gender group format and the potential impact of gender on outcome were examined. Materials and Methods: Participants (n = 39) were Veterans enrolled in a post-traumatic stress disorder (PTSD) Clinic at a large VA Medical Center. Veterans participated in one of four mixed-gender STAIR groups and completed self-report questionnaires of PTSD symptoms and general psychological distress at pre-treatment and post-treatment. Institutional review board approval was obtained for this study. Results: There was significant pre-treatment to post-treatment improvements in PTSD symptoms as measured by the Post-traumatic Stress Checklist (PCL) (Cohen's d = 0.91), as well as in general psychological distress as measured by the Brief Symptom Inventory (BSI) (Cohen's d = 0.90). Change in PTSD symptoms from pre-treatment to post-treatment did not differ across gender. However, the interaction between gender and time on change in (BSI) was significant, where change in general psychological distress significantly decreased from pre-treatment to post-treatment for male Veterans but not for female Veterans. Conclusion: The results from this study demonstrate the feasibility and initial effectiveness of STAIR delivered in a mixed-gender group format for Veterans with PTSD. It should be noted, however, that male Veterans benefited more from this approach than female Veterans. The findings suggest the value of investigating Veterans' attitudes and beliefs about the benefits and drawbacks of mixed-gender group therapy for trauma-related difficulties.

Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App.

Objective: Clinicians' perceptions of CBT-I Coach, a patient-facing mobile app for cognitive-behavioral therapy for insomnia (CBT-I), are critical to its adoption and integration into practice. Diffusion of innovations theory emphasizes the influence of perceptions, including the relative advantage to current practice, the compatibility to clinicians' needs, the complexity, the innovation's trialability, and observability. This study intended to evaluate the use and perceptions of CBT-I Coach among Veterans Affairs (VA)-trained CBT-I clinicians. Participants and Methods: Clinicians (N = 108) were surveyed about their use, feedback, and perceptions of CBT-I Coach a year after the app became available. Results: Overall perceptions of CBT-I Coach were favorable. Fifty percent of clinicians reported using CBT-I Coach, with 98% intending to continue use. The app was perceived to increase sleep diary completion and homework compliance. Clinicians viewed the app as providing accessibility to helpful tools and improving patient engagement. Of those not using the app, 83% endorsed intention to use it. Reasons for nonuse were lack of patient access to smart phones, not being aware of the app, not having time to learn it, and inability to directly access app data. Those who reported using CBT-I Coach had more favorable perceptions across all constructs (p < .01 - p < .001), except relative advantage, compared to nonusers. Users perceived it as less complex and more compatible with their practice than nonusers. Conclusions: Continued efforts are needed to increase adoption and enhance use of CBT-I Coach, as well as study if reported benefits can be evidenced more directly.

Telemental Health Delivery of Skills Training in Affective and Interpersonal Regulation (STAIR) for Rural Women Veterans Who Have Experienced Military Sexual Trauma.

This pilot study assessed the feasibility, acceptability, and initial efficacy of a skills-focused treatment delivered via video teleconferencing (VTC) to women veterans living in rural areas who had experienced military sexual trauma (MST). The Skills Training in Affective and Interpersonal Regulation (STAIR) program focuses on teaching emotion management and interpersonal skills in 8 to 10 sessions. The STAIR program may be a good fit for individuals in rural areas for whom social isolation and low social support are particularly problematic. Clinic-to-clinic VTC was used to connect a STAIR therapist with veterans for weekly individual therapy sessions. The participants (n = 10) reported high satisfaction with the intervention and would recommend the program to others. There were significant pretreatment to posttreatment improvements in social functioning, Hedge's g = 1.41, as well as in posttraumatic stress disorder symptoms, Hedge's g = 2.35; depression, Hedge's g = 1.81; and emotion regulation, Hedge's g = 2.32. This is the first report of the successful application of a skills-focused treatment via VTC for women veterans.

Depression as a moderator of STAIR Narrative Therapy for women with post-traumatic stress disorder related to childhood abuse.

Background: Depression among those who have experienced childhood abuse is associated with earlier onset, more persistent and severe symptoms, more frequent relapse, and poorer treatment outcomes across a variety of psychiatric disorders. In addition, individuals with a history of childhood abuse are more likely to develop post-traumatic stress disorder (PTSD) co-occurring with depression. Objective: This study evaluated whether severity of depression moderated the outcome in a PTSD treatment for childhood abuse survivors. Specifically, we assessed whether individuals with significant depression obtained better outcomes when provided with a two-module treatment which included a skills training component with behavioral activation interventions, Skills Training in Affective and Interpersonal Regulation (STAIR) followed by a trauma-focused component, Narrative Therapy, as compared to two control conditions where one component (STAIR or Narrative Therapy) was replaced with Supportive Counseling. Method: Participants were 104 women with PTSD related to childhood abuse. Participants were randomized into three conditions: (1) STAIR plus Narrative Therapy (SNT), (2) STAIR plus Supportive Counseling (SSC), and (3) Supportive Counseling plus Narrative Therapy (SCNT). Clinician-Administered PTSD Scale for DSM-IV (CAPS-IV) PTSD symptom severity was assessed at pre-treatment, post-treatment, and 3 and 6 month follow-up. Results: Participants with severe depression showed superior PTSD symptom reduction following SNT, while those in the other two conditions experienced a loss of improvement after treatment ended. A similar finding was obtained among those with moderate depression, while among those with low levels of depression, outcomes did not differ across the three treatment conditions. Conclusions: Childhood abuse survivors with severe depression obtained superior outcomes in a treatment that combined skills training with trauma-focused work. Skills packages which contain behavioral activation interventions in combination with trauma-focused work may be particularly beneficial for patients with childhood abuse and severe depression.

Planteamiento: La depresión entre los que han sufrido malos tratos en la infancia se asocia con un inicio más temprano, síntomas más persistentes y graves, recaídas más frecuentes y peores resultados de tratamiento en una variedad de trastornos psiquiátricos. Además, las personas con abuso infantil son más propensas a desarrollar un TEPT concurrente con la depresión. Objetivo: Este estudio evaluó si la gravedad de la depresión moderaba el resultado en un tratamiento de TEPT para sobrevivientes de maltrato infantil. Específicamente, evaluamos si los individuos con depresión significativa obtenían mejores resultados cuando se les proporcionaba un tratamiento de dos módulos que incluía un componente de entrenamiento en habilidades con intervenciones de activación conductual, Entrenamiento de habilidades en regulación afectiva e Interpersonal (STAIR, siglas en inglés de Skills Training in Affective and Interpersonal Regulation), seguido de un componente centrado en el trauma, Terapia Narrativa (TN), en comparación con dos condiciones de control en las que un componente (el STAIR o la TN) se sustituía por terapia de apoyo (TA). Métodos: Los participantes fueron 104 mujeres con TEPT relacionado con maltrato infantil. Los participantes fueron asignados al azar a tres condiciones: (1) STAIR más Terapia Narrativa (STN) (2) STAIR más terapia de apoyo (STA) y (3) terapia de apoyo más Terapia Narrativa (TATN). Se evaluó la gravedad de los síntomas de TEPT con el CAPS-IV al inicio del tratamiento, después del tratamiento y en el seguimiento a los 3 y 6 meses. Resultados: Los participantes con depresión grave mostraron una mayor reducción de los síntomas de TEPT después de la Terapia Narrativa de STAIR, mientras que los de las otras dos condiciones experimentaron una pérdida de mejoría una vez finalizado el tratamiento. Se encontró un resultado similar entre los que tenían depresión moderada, mientras que entre los que tenían un nivel bajo de depresión, los resultados no difirieron entre las tres condiciones de tratamiento. Conclusión: Los supervivientes de maltrato infantil con depresión grave obtuvieron resultados superiores en un tratamiento que combina entrenamiento de habilidades con el trabajo centrado en el trauma. Los paquetes de habilidades que contienen intervenciones de activación conductual en combinación con el trabajo centrado en el trauma pueden ser particularmente beneficiosos para pacientes con abuso infantil y depresión grave.

Piloting Specialized Mental Health Care for Rural Women Veterans Using STAIR Delivered via Telehealth: Implications for Reducing Health Disparities.

This pilot project implemented a mental health program, STAIR, targeting basic skills in mood management training and social functioning for women veterans with military-related trauma who live in rural areas. We report on outreach and implementation procedures, the women veterans' reactions to the program, and lessons learned.

CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia.

STUDY OBJECTIVES: This paper describes CBT-I Coach, a patient-facing smartphone app designed to enhance cognitive behavioral therapy for insomnia (CBT-I). It presents findings of two surveys of U.S. Department of Veterans Affairs (VA) CBT-I trained clinicians regarding their perceptions of CBT-I Coach before it was released (n = 138) and use of it two years after it was released (n = 176). METHODS: VA-trained CBT-I clinicians completed web-based surveys before and two years after CBT-I Coach was publicly released. RESULTS: Prior to CBT-I Coach release, clinicians reported that it was moderately to very likely that the app could improve care and a majority (87.0%) intended to use it if it were available. Intention to use the app was predicted by smartphone ownership (ß = 0.116, p < 0.05) and perceptions of relative advantage to existing CBT-I practices (ß = 0.286, p < 0.01), compatibility with their own needs and values (ß = 0.307, p < 0.01), and expectations about the complexity of the app (ß = 0.245, p < 0.05). Two years after CBT-I Coach became available, 59.9% of participants reported using it with patients and had favorable impressions of its impact on homework adherence and outcomes. CONCLUSIONS: Findings suggest that before release, CBT-I Coach was perceived to have potential to enhance CBT-I and address common adherence issues and clinicians would use it. These results are reinforced by findings two years after it was released suggesting robust uptake and favorable perceptions of its value.

Anxiety and Related Disorders and Concealment in Sexual Minority Young Adults.

Sexual minorities face greater exposure to discrimination and rejection than heterosexuals. Given these threats, sexual minorities may engage in sexual orientation concealment in order to avoid danger. This social stigma and minority stress places sexual minorities at risk for anxiety and related disorders. Given that three fourths of anxiety disorder onset occurs before the age of 24, the current study investigated the symptoms of generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and depression in sexual minority young adults relative to their heterosexual peers. Secondarily, the study investigated sexual orientation concealment as a predictor of anxiety and related disorders. A sample of 157 sexual minority and 157 heterosexual young adults matched on age and gender completed self-report measures of the aforementioned disorders, and indicated their level of sexual orientation concealment. Results revealed that sexual minority young adults reported greater symptoms relative to heterosexuals across all outcome measures. There were no interactions between sexual minority status and gender, however, women had higher symptoms across all disorders. Sexual minority young women appeared to be at the most risk for clinical levels of anxiety and related disorders. In addition, concealment of sexual orientation significantly predicted symptoms of social phobia. Implications are offered for the cognitive and behavioral treatment of anxiety and related disorders in this population.

PTSD and Trauma-Related Difficulties in Sexual Minority Women: The Impact of Perceived Social Support.

This study examined posttraumatic stress disorder (PTSD) and related symptoms among sexual minority (SM) and heterosexual women and the influence of social support on the relationship between SM status and symptoms. We hypothesized that SM women would endorse higher symptoms of PTSD and related difficulties and that social support would moderate the relationship between SM status and symptoms. The sample, women seeking treatment for PTSD related to interpersonal violence (n = 477; mean age = 36.07 years; 22.9% SM) completed clinician-administered measures of PTSD and self-report measures of trauma-related difficulties and social support. The rate of PTSD diagnosis was higher for SM women. Social support and SM status were significantly associated with suicidality, self-perceptions, depression, somatic complaints, and functional impairment. The interaction between social support and SM status was significant for both functional impairment (ß = -.26) and somatic complaints (ß = -.39). High social support had an equal, positive effect among SM and nonminority women, whereas low social support had a greater negative impact among SM women. Results suggested the particular salience of social support on functioning and symptom severity among SM women and the potential importance of including interventions addressing social support into PTSD treatments for SM women.

Heterocentric language in commonly used measures of social anxiety: recommended alternate wording.

A number of self-report measures of social anxiety contain language that appears to assume heterosexuality. It is unclear how such items should be answered by individuals who are not exclusively heterosexual, which may lead to inaccurate measurement of symptoms, perpetuation of stigma, and alienation of respondents. More specific wording could improve measurement accuracy for sexual minorities as well as heterosexual respondents. Gender-neutral wording was developed for items containing the phrase "opposite sex" in commonly used self-report measures of social anxiety (Interaction Anxiousness Scale [Leary, 1983], Social Avoidance and Distress Scale [Watson & Friend, 1969], Social Interaction Anxiety Scale [Mattick & Clarke, 1998], and Social Phobia and Anxiety Inventory [Turner, Beidel, Dancu, & Stanley, 1989]). Undergraduate college students (N=405; mean age=19.88, SD=2.05) completed measures containing original and revised items. Overall, results indicated that the alternate-worded items demonstrated equivalent or slightly stronger psychometric properties compared to original items. Select alternate-worded items are recommended for clinical and research use, and directions for future research are recommended.

The Pittsburgh Sleep Quality Index in older primary care patients with generalized anxiety disorder: psychometrics and outcomes following cognitive behavioral therapy.

The Pittsburgh Sleep Quality Index (PSQI) is a widely used, comprehensive self-report measure of sleep quality and impairment, which has demonstrated good psychometric properties within various populations, including older adults. However, the psychometric properties of the PSQI and its component scores have not been evaluated for older adults with generalized anxiety disorder (GAD). Additionally, changes in PSQI global or component scores have not been reported following cognitive-behavioral treatment (CBT) of late-life GAD. This study examined (1) the psychometric properties of the PSQI within a sample of 216 elderly primary care patients age 60 or older with GAD who were referred for treatment of worry and/or anxiety; as well as (2) response to CBT, relative to usual care, for 134 patients with principal or coprincipal GAD. The PSQI demonstrated good internal consistency reliability and adequate evidence of construct validity. Those receiving CBT experienced greater reductions in PSQI global scores at post-treatment, relative to those receiving usual care. Further, PSQI global and component scores pertaining to sleep quality and difficulties falling asleep (i.e., sleep latency and sleep disturbances) demonstrated response to treatment over a 12-month follow-up period. Overall, results highlight the usefulness of the PSQI global and component scores for use in older adults with GAD.

A preliminary investigation of worry content in sexual minorities.

This preliminary study examined the nature of worry content of lesbians, gay men, and bisexual individuals and the relationship between worry related to sexual orientation and mental health. A community sample of 54 individuals identifying as sexual minorities was recruited from two cities in the Great Plains to complete a packet of questionnaires, including a modified Worry Domains Questionnaire (WDQ; Tallis, Eysenck, & Mathews, 1992) with additional items constructed to assess worry over discrimination related to sexual orientation, and participate in a worry induction and verbalization task. The content of self-reported worries was consistent with those reported in prior investigations of worry content, and worry related to sexual orientation was not found to be elevated compared to other topics. However, degree of worry related to sexual orientation was significantly associated with increased negative affect, depressive symptoms, and internalized homophobia and decreased quality of life and positive affect. Implications of these findings, limitations, and future research issues are discussed.

Cognitive-Behavioral Therapy for Immigrants Presenting With Social Anxiety Disorder: Two Case Studies.

Cognitive-behavioral therapy (CBT) for the treatment of Social Anxiety Disorder (SAD) has demonstrated efficacy in numerous randomized trials. However, few studies specifically examine the applicability of such treatment for ethnic minority clients. Thus, the purpose of this article is to present two case studies examining the utility of individualized CBT for SAD with two clients who immigrated to the United States, one from Central America and one from China, for whom English was not their primary language. Both clients demonstrated improvement on a semi-structured interview and self-report measures. Necessary adaptations were modest, suggesting that therapy could be conducted in a culturally sensitive manner without much deviation from the treatment protocol. Results are discussed in terms of adapting treatment to enhance acceptability for and better fitting the needs of ethnic minority clients and non-native speakers of English. Implications for treating ethnic minority clients, as well as the practice of culturally sensitive treatment, are discussed.

The role of courage on behavioral approach in a fear-eliciting situation: a proof-of-concept pilot study.

The current study was conducted to assess courage, defined as behavioral approach despite the experience of fear, in an effort to better understand its relationship with anxiety, fear, and behavioral approach. Thirty-two participants who completed a measure of courage and reported elevated spider fears during an earlier screening participated in a Behavioral Approach Test where they were shown a display of four taxidermied tarantulas and asked to move their hand as close to the spiders as they felt comfortable doing. After controlling for scores on measures of spider fears, courage scores were significantly associated with approach distance to the spiders, such that participants with greater courage moved closer to the spiders. This study advances knowledge about the relationship between courage and fear. Based on our findings, future studies can explore the extent to which (a) courage mediates willingness to engage in therapeutic exposure in treatment, and (b) whether courage can be augmented in treatment prior to implementing exposure therapy.

The utility of the Generalized Anxiety Disorder Severity Scale (GADSS) with older adults in primary care.

BACKGROUND: The Generalized Anxiety Disorder Severity Scale (GADSS) is an interview rating scale designed specifically for assessing symptom severity of generalized anxiety disorder (GAD), which has demonstrated positive psychometric data in a sample of adult primary care patients with GAD and panic disorder. However, the psychometric properties of the GADSS have not been evaluated for older adults. METHODS: This study evaluated the psychometric properties of the GADSS, administered via telephone, with a sample of older primary care patients (n=223) referred for treatment of worry and/or anxiety. RESULTS: The GADSS demonstrated adequate internal consistency, strong inter-rater reliability, adequate convergent validity, poor diagnostic accuracy, and mixed discriminant validity. CONCLUSIONS: Results provide mixed preliminary support for use of the GADSS with older adults.