Applying a Process-Oriented Model of Cultural Competence to Behavioral Activation for Depression.

Efforts to integrate cultural competence and evidence-based treatments (EBTs) typically take the form of cultural adaptations of EBTs, characterized by modifications to the existing treatment based on presumed cultural notions of a given race or ethnic group. Much less attention has been given to ways EBTs can integrate a process model of cultural competence, which focuses on what clinicians do in-session to identify and integrate key cultural factors for a given individual in the treatment. Our objective is to consider how a process model of cultural competence (Shifting Cultural Lenses) can be integrated with an EBT (Behavioral Activation). We present a theoretical rationale for integrating the SCL model with BA and illustrate this integration, which clinician provides an additional approach to bringing culture to treatments and shows promise for identifying clinicians' in-session behaviors that reflect cultural competence.

Differential associations between interpersonal variables and quality-of-life in a sample of college students.

PURPOSE: Humans are fundamentally social beings, and the relationships we form with others are crucial for our well-being. Research across a variety of domains has established the association between a variety of interpersonal factors and health outcomes, including quality-of-life. However, there is a need for a more integrative, holistic analysis of these variables and how they relate to one another. METHODS: Undergraduate students (n = 1456) from four universities across the United States completed self-report measures of their quality-of-life and a variety of interpersonal factors identified as important predictors across the literature. We examined zero-order correlations between these measures and quality-of-life, estimated a path model to look at unique variance accounted for by each, and finally used network analysis to examine the network of direct and indirect associations among these variables and quality-of-life. RESULTS: Loneliness had the strongest association with quality-of-life across all analyses. When examining the unique association between quality-of-life and each interpersonal variable, six remained statistically significant: loneliness, social support, social connectedness, emotional intelligence, intimacy with one's romantic partner, and empathic concern. These results were supported by the network model, which found direct associations between quality-of-life and these six variables as well as indirect associations with all other interpersonal variables in the model. CONCLUSIONS: Results from this research suggest that interpersonal factors in general, and loneliness in particular, are strongly associated with quality-of-life. Future research is needed to establish the direction of these effects and examine for whom these findings are generalizable.

Addressing microaggressions in racially charged patient-provider interactions: a pilot randomized trial.

BACKGROUND: Racial bias in medical care is a significant public health issue, with increased focus on microaggressions and the quality of patient-provider interactions. Innovations in training interventions are needed to decrease microaggressions and improve provider communication and rapport with patients of color during medical encounters. METHODS: This paper presents a pilot randomized trial of an innovative clinical workshop that employed a theoretical model from social and contextual behavioral sciences. The intervention specifically aimed to decrease providers' likelihood of expressing biases and negative stereotypes when interacting with patients of color in racially charged moments, such as when patients discuss past incidents of discrimination. Workshop exercises were informed by research on the importance of mindfulness and interracial contact involving reciprocal exchanges of vulnerability and responsiveness. Twenty-five medical student and recent graduate participants were randomized to a workshop intervention or no intervention. Outcomes were measured via provider self-report and observed changes in targeted provider behaviors. Specifically, two independent, blind teams of coders assessed provider emotional rapport and responsiveness during simulated interracial patient encounters with standardized Black patients who presented specific racial challenges to participants. RESULTS: Greater improvements in observed emotional rapport and responsiveness (indexing fewer microaggressions), improved self-reported explicit attitudes toward minoritized groups, and improved self-reported working alliance and closeness with the Black standardized patients were observed and reported by intervention participants. CONCLUSIONS: Medical providers may be more likely to exhibit bias with patients of color in specific racially charged moments during medical encounters. This small-sample pilot study suggests that interventions that directly intervene to help providers improve responding in these moments by incorporating mindfulness and interracial contact may be beneficial in reducing racial health disparities.

Effects of Functional Analytic Psychotherapy Therapist Training on Therapist Factors Among Therapist Trainees in Singapore: A Randomized Controlled Trial.

Functional Analytic Psychotherapy (FAP) is a behavioral psychotherapy intervention that emphasizes the development of an intimate and intense therapeutic relationship as the vehicle of therapeutic change. Recently, research has provided preliminary support for a FAP therapist training (FAPTT) protocol in enhancing FAP competency. The present study aimed to expand on this research by examining the effects of FAPTT on FAP-specific skills and competencies and a set of broadly desirable therapist qualities (labelled awareness, courage and love in FAPTT) in a sample of therapist trainees in Singapore. The study also evaluated the feasibility and acceptability of FAP in the Singaporean context. Twenty-five students enrolled in a master's in clinical psychology program were recruited and randomly assigned to receive either eight weekly sessions of a FAPTT course or to a waitlist condition. All participants completed measures assessing empathy, compassionate love, trait mindfulness, authenticity and FAP-specific skills and competencies pre- and post-training, and at 2-month follow-up. A post-course evaluation was administered to obtain participants' qualitative feedback. Results indicated that compared with the waitlisted group, FAPTT participants reported significant increases in overall empathy, FAP skill and treatment acceptability from pre- to post-training. Improvements were observed on several outcome variables at 2-month follow-up. Participants reported finding the training to be both feasible and acceptable, although several raised issues related to the compatibility of the treatment with the local cultural context. Overall, the findings suggest that FAPTT is effective for improving specific FAP competencies and selected broadly desirable therapist qualities among therapist trainees. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Functional Analytic Therapy (FAP) therapist training protocol was effective in improving empathy and FAP skills among Singaporean therapist trainees. These improvements were maintained at 2-month follow-up. The training was found to be acceptable in the Singaporean context, although several adaptations were suggested to increase the compatibility between FAP principles and local cultural norms.

A learning theory account of depression.

Learning theory provides a foundation for understanding and deriving treatment principles for impacting a spectrum of functional processes relevant to the construct of depression. While behavioral interventions have been commonplace in the cognitive behavioral tradition, most often conceptualized within a cognitive theoretical framework, recent years have seen renewed interest in more purely behavioral models. These modern learning theory accounts of depression focus on the interchange between behavior and the environment, mainly in terms of lack of reinforcement, extinction of instrumental behavior, and excesses of aversive control, and include a conceptualization of relevant cognitive and emotional variables. These positions, drawn from extensive basic and applied research, cohere with biological theories on reduced reward learning and reward responsiveness and views of depression as a heterogeneous, complex set of disorders. Treatment techniques based on learning theory, often labeled Behavioral Activation (BA) focus on activating the individual in directions that increase contact with potential reinforcers, as defined ideographically with the client. BA is considered an empirically well-established treatment that generalizes well across diverse contexts and populations. The learning theory account is discussed in terms of being a parsimonious model and ground for treatments highly suitable for large scale dissemination.

Depression stigma and treatment preferences among Orthodox and non-Orthodox Jews.

Anecdotal reports of increased stigma toward mental illness among Orthodox Jews seems to conflict with an existing literature describing less stigmatization toward depression among Jewish individuals. This online survey study investigated stigma toward depression and treatment preference among Orthodox and non-Orthodox Jews (N = 391). All participants were presented with a depression vignette to assess for stigma and then randomized to a vignette depicting a treatment modality (behaviorally oriented or insight oriented) to assess for treatment preference across several delivery options (individual, group, or Internet). Results indicated elevated depression stigma among Orthodox Jews as expressed by elevated levels of secrecy, treatment-seeking stigma, family/marriage stigma, and stigmatizing experiences, but not attitudinal social distancing. No group differences were found with respect to overall treatment preference, treatment modality, or manner of delivery. Overall, participants preferred individual therapy more than group and Internet therapy and preferred group therapy more than Internet therapy. Clinical and research implications are discussed.

Characterizing the momentary association between loneliness, depression, and social interactions: Insights from an ecological momentary assessment study.

Evidence suggests that loneliness causes people to feel more depressed. It is unknown, however, why this association occurs and whether momentary versus chronic experiences of loneliness are implicated. Theoretical accounts suggest that momentary feelings of loneliness produce two competing motivations: social reaffiliation and social withdrawal. Social affiliation is protective against depression; social withdrawal, in contrast, is a risk factor. Thus, engaging in frequent and high-quality interactions following experiences of loneliness may protect against subsequent depression. We tested this hypothesis using a random-interval experience sampling design (5x/day/day, 14 days; Nobs = 6568) with a racially/ethnically diverse sample of adults with elevated depression symptoms (N = 102). Momentary loneliness was associated with depressed mood at the same time point and âˆ¼2.5h and âˆ¼5h later. Frequency and quality of social interaction did not moderate these associations. Findings suggest that momentary feelings of loneliness may be an important target for clinical intervention.

Job stress and dyadic synchrony in police marriages: a preliminary investigation.

Despite reports documenting adverse effects of stress on police marriages, few empirical studies focus on actual emotional behaviors of officers and spouses. In this preliminary investigation, 17 male police officers and their nonpolice wives completed daily stress diaries for 1 week and then participated in a laboratory-based discussion about their respective days. Conversations were video-recorded and coded for specific emotional behaviors reflecting hostility and affection, which are strong predictors of marital outcomes. We examined associations between officers' job stress (per diaries and the Police Stress Survey) and couples' emotional behavior (mean levels and behavioral synchrony) using a dyadic repeated measures design capitalizing on the large number of observations available for each couple (1020 observations). When officers reported more job stress, they showed less hostility, less synchrony with their wives' hostility, and more synchrony with their wives' affection; their wives showed greater synchrony with officers' hostility and less synchrony with officers' affection. Therefore, for officers, greater job stress was associated with less behavioral negativity, potentially less attunement to wives' negativity, but potentially greater attunement to wives' affection-perhaps a compensatory strategy or attempt to buffer their marriage from stress. These attempts may be less effective, however, if, as our synchrony findings may suggest, wives are focusing on officers' hostility rather than affection. Although it will be important to replicate these results given the small sample, our findings reveal that patterns of behavioral synchrony may be a key means to better understand how job stress exacts a toll on police marriages.

Behavioural activation: history, evidence and promise.

Behavioural activation holds promise to reduce the global burden of depression as a treatment approach that is effective, easy to teach, scalable and acceptable to providers and patients across settings and cultures. This editorial reviews the history of behavioural activation, what it is, current evidence for its use and future directions.

Development and psychometric evaluation of the Milwaukee Psychotherapy Expectations Questionnaire.

The Milwaukee Psychotherapy Expectations Questionnaire (MPEQ) was developed to measure clients' expectations about the components and effects of therapy. Items were generated rationally based upon the theoretical literature and existing expectancy measures. An exploratory factor analysis revealed a 2-factor solution, comprised of Process Expectations and Outcome Expectations, which was supported by confirmatory factor analyses in three additional samples. The measure demonstrated good internal consistency and test-retest reliability, along with support for convergent, discriminant, and predictive validity. These results present initial evidence for the utility of the MPEQ in assessing both process and outcome expectations in therapy.

A qualitative study of microaggressions against African Americans on predominantly White campuses.

BACKGROUND: Pierce's (The Black seventies: an extending horizon book, 1970) conception of "subtle and stunning" daily racial offenses, or microaggressions, remains salient even 50 years after it was introduced. Microaggressions were defined further by Sue and colleagues (Am Psychol 62:271, 2007), and this construct has found growing utility as the deleterious effects of microaggressions on the health of people of color continues to mount. Microaggressions are common on campuses and contribute to negative social, academic, and mental health outcomes. METHOD: This paper explores how Black college students' experiences correspond to or differ from the microaggression types originally proposed by Sue et al. (Am Psychol 62:271, 2007). Themes were identified from focus group data of students of color (N = 36) from predominately White institutions (PWIs) of higher learning (N = 3) using interpretative phenomenological analysis. RESULTS: We identified 15 categories of racial microaggressions, largely consistent with the original taxonomy of Sue et al. but expanded in several notable ways. New categories in our data and observed by other researchers, included categories termed Connecting via Stereotypes, Exoticization and Eroticization, and Avoidance and Distancing. Lesser studied categories identified included Sue et al.'s Denial of Individual Racism, and new categories termed Reverse Racism Hostility, Connecting via Stereotypes, and Environmental Attacks. DISCUSSION: While previous literature has either embraced the taxonomy developed by Sue and colleagues or proposed a novel taxonomy, this study synthesized the Sue framework in concert with our own focus group findings and the contributions of other researchers. Improving our understanding of microaggressions as they impact people of color may better allow for improved understanding and measurement of this important construct.

A comparison of contextual and biomedical models of stigma reduction for depression with a nonclinical undergraduate sample.

Stigma reduction programs are dominated by a biomedical model that presents depression as a medical illness. Alternately, a contextual model emphasizes that one should not be blamed for environmental influences. This study compared biomedical, contextual, and control stigma reduction programs to each other and to a no-program control. The main hypotheses were that the contextual program would have the greatest impact and that a match between participants' beliefs about depression and the model presented would moderate this effect. Seventy-four participants were randomized to the 3 programs and 12 participants served as a no-program control. The contextual and control programs reduced stigma significantly compared with the no-program control, whereas the biomedical program did not. Beliefs about depression moderated this effect only for the biomedical condition. Contextual and control programs seem to be effective but a biomedical model may be risky for those who disagree with the model. Theoretical implications are discussed.

Depression self-stigma: a new measure and preliminary findings.

It is widely recognized that stigmatization of mental disorders leads stigmatized individuals to avoid treatment altogether or discontinue treatment prematurely. Literature suggests that the impact of stigma may differ by diagnosis; however, previous attempts to measure self-stigma have not been disorder specific. This study sought to develop the Depression Self-Stigma Scale (DSSS) and identify distinct constructs associated with depression self-stigma. Items for the initial administration of the DSSS were developed through careful review of existing measures and the literature on stigma and depression. Items were administered to undergraduates and community members with self-reported depression (N = 391). Results indicated 5 factors (general self-stigma, secrecy, public stigma, treatment stigma, and stigmatizing experiences) with good factor structure, internal consistency, and evidence for construct validity.

Depression stigma in a predominantly low income African American sample with elevated depressive symptoms.

It is widely recognized that stigmatization of depression leads individuals with depression to avoid treatment and discontinue treatment prematurely. However, this research has been conducted with predominantly White samples and there is limited research on stigma of depression and how it relates to previous treatment seeking among African Americans. The current study examined stigma of depression and related constructs in a predominantly low income African American sample with elevated depressive symptoms. Specifically, general self-stigma, secrecy, public stigma, treatment stigma, and stigmatizing experiences, as well as depression severity, and whether these factors predicted previous treatment seeking for depression were explored. Previous treatment seeking significantly predicted decreased public stigma and increased self-stigma. Implications and future directions are discussed.

The nature of clinical depression: symptoms, syndromes, and behavior analysis.

In this article we discuss the traditional behavioral models of depression and some of the challenges analyzing a phenomenon with such complex and varied features. We present the traditional model and suggest that it does not capture the complexity of the phenomenon, nor do syndromal models of depression that dominate the mainstream conceptualization of depression. Instead, we emphasize ideographic analysis and present depression as a maladaptive dysregulation of an ultimately adaptive elicited emotional response. We emphasize environmental factors, specifically aversive control and private verbal events, in terms of relational frame theory, that may transform an adaptive response into a maladaptive disorder. We consider the role of negative thought processes and rumination, common and debilitating aspects of depression that have traditionally been neglected by behavior analysts.

Anxiety, Stress, and Trauma Symptoms in African Americans: Negative Affectivity Does Not Explain the Relationship between Microaggressions and Psychopathology.

Prior research has demonstrated a clear relationship between experiences of racial microaggressions and various indicators of psychological unwellness. One concern with these findings is that the role of negative affectivity, considered a marker of neuroticism, has not been considered. Negative affectivity has previously been correlated to experiences of racial discrimination and psychological unwellness and has been suggested as a cause of the observed relationship between microaggressions and psychopathology. We examined the relationships between self-reported frequency of experiences of microaggressions and several mental health outcomes (i.e., anxiety [Beck Anxiety Inventory], stress [General Ethnic and Discrimination Scale], and trauma symptoms [Trauma Symptoms of Discrimination Scale]) in 177 African American and European American college students, controlling for negative affectivity (the Positive and Negative Affect Schedule) and gender. Results indicated that African Americans experience more racial discrimination than European Americans. Negative affectivity in African Americans appears to be significantly related to some but not all perceptions of the experience of discrimination. A strong relationship between racial mistreatment and symptoms of psychopathology was evident, even after controlling for negative affectivity. In summary, African Americans experience clinically measurable anxiety, stress, and trauma symptoms as a result of racial mistreatment, which cannot be wholly explained by individual differences in negative affectivity. Future work should examine additional factors in these relationships, and targeted interventions should be developed to help those suffering as a result of racial mistreatment and to reduce microaggressions.

Exploring the relationship between activities and emotional experience using a diary in a mental health inpatient setting.

Mental health inpatient milieus have repeatedly been found to be associated with passivity, social disengagement, and low levels of interaction with staff. However, little is known about patients' experiences related to different ward activities. In the present study, we aimed to study the reports of activities and associated experiences of patients admitted to acute psychiatric inpatient wards. Disengaged, inactive, and solitary activities were hypothesized to be associated with less reward and more distress than their counterparts. We also aimed to investigate if such activities predicted distress, and if they were associated with clinical severity. Participants (n = 102) recorded their activities along with concurrent ratings of reward and distress in a structured 1-day diary, and nurses provided clinical severity ratings. On average, 3.74 of the 11 hours assessed (34%) were spent doing nothing, only 0.88 hours (8%) were spent with staff, and most of the time was spent in solitude. Doing nothing, being alone, and passivity were associated with the greatest levels of distress and lowest levels of reward, whereas informal socializing demonstrated the opposite pattern. Distress was not predicted by activity or reward when adjusting for baseline distress. Clinical severity was not associated with the amount of time spent alone or the experience of reward during activity. In conclusion, the risk for passivity and social disengagement during admission prevails. This activity pattern could have detrimental emotional consequences and warrants action, but more studies are needed to determine if activity actually precedes emotional experience.

A comprehensive review of research on Functional Analytic Psychotherapy.

Functional Analytic Psychotherapy (FAP; Kohlenberg & Tsai, 1991) is a transdiagnostic approach to outpatient psychotherapy that presented guidelines to instantiate the behavioral principle of natural, social reinforcement applied to idiographic behavioral targets within a genuine and authentic psychotherapy relationship. We present the first comprehensive review of research on FAP, including qualitative studies, uncontrolled and controlled single-case designs, group designs, and studies on training therapists in FAP. We conclude that current research support for FAP is promising but not sufficient to justify claims that FAP is research-supported for specific psychiatric disorders. There is stronger support for FAP's mechanism of therapist-as-social reinforcer: FAP techniques, when appropriately applied to idiographically defined behavioral problems-primarily in the realm of social functioning-produce positive change in those behaviors.

A randomized controlled trial of an online, modular, active learning training program for behavioral activation for depression.

OBJECTIVE: This randomized-controlled trial assessed the efficacy of a trainer-led, active-learning, modular, online behavioral activation (BA) training program compared with a self-paced online BA training with the same modular content. METHOD: Seventy-seven graduate students (M = 30.3 years, SD = 6.09; 76.6% female) in mental health training programs were randomly assigned to receive either the trainer-led or self-paced BA training. Both trainings consisted of 4 weekly sessions covering 4 core BA strategies. Primary outcomes were changes in BA skills as measured by an objective role-play assessment and self-reported use of BA strategies. Assessments were conducted at pre-, post-, and 6-weeks after training. A series of longitudinal mixed effect models assessed changes in BA skills and a longitudinal model implemented with generalized estimating equations assessed BA use over time. RESULTS: Significantly greater increases in total BA skills were found in the trainer-led training condition. The trainer-led training condition also showed greater increases in all core BA skills either at posttraining, follow-up, or both. Reported use of BA strategies with actual clients increased significantly from pre- to posttraining and maintained at follow-up in both training conditions. CONCLUSIONS: This trial adds to the literature on the efficacy of online training as a method to disseminate BA. Online training with an active learning, modular approach may be a promising and accessible implementation strategy. Additional strategies may need to be paired with the online BA training to assure the long-term implementation and sustainability of BA in clinical practice. (PsycINFO Database Record