More than one way to say I love you: An Internet-based intervention for training flexible thinking in romantic relationships.

OBJECTIVES: This study developed and pilot-tested an adaptation of Cognitive Bias Modification (CBM) to target two aspects of relational flexibility in couples: the ability to generate alternative perspectives, and the ability to respond nondefensively when alternative partner perspectives are raised within challenging relationship situations (referred to as flexibility in partner perspectives). METHODS: CBM-FlexC training materials were developed in Phase 1, and expert users (N = 4) and end-point users (N = 7) provided qualitative feedback. Feasibility and preliminary efficacy of CBM-FlexC were evaluated in Phase 2, using an online sample of distressed couples (N = 18). Using a multiple baseline design, participants completed three baseline assessments, six CBM-FlexC sessions over 2 weeks, and a 1-month follow-up. RESULTS: CBM-FlexC training resulted in greater flexibility in partner perspectives, relationship satisfaction, and general psychological flexibility compared to baseline, and improvements were maintained 1-month after training when using mixed-effects models. However, analyses of reliable change (based on graphical inspection and the Reliable Change Index) indicated that most participants did not experience reliable improvement in flexibility in partner perspectives, or relationship satisfaction. CONCLUSION: This pilot study provides some positive signals regarding the potential efficacy of CBM-FlexC, while pointing to the need for further development to strengthen its effects.

Minimal Effect of Messaging on Engagement in a Digital Anxiety Intervention.

This study evaluated the effectiveness of different recruitment messages for encouraging enrollment in a digital mental health intervention (DMHI) for anxiety among 1,600 anxious patients in a large healthcare system. Patients were randomly assigned to receive a standard message, or one of five messages designed to encourage enrollment: Three messages offered varying financial incentives, one message offered coaching, and one message provided consumer testimonials. Patients could then click a link in the message to visit the DMHI website, enroll, and start the first session. We examined the effects of message features and message length (short vs. long) on rates of site clicks, enrollment, and starting the first session. We also tested whether demographic and clinical factors derived from patients' electronic health records were associated with rates of enrollment and starting the first session to understand the characteristics of patients most likely to use DMHIs in this setting. Across messages, 19.4% of patients clicked a link to visit the DMHI website, but none of the messages were significantly associated with rates of site clicks, enrollment, or starting the first session. Females (vs. males) had a greater probability of enrollment. No other demographic or clinical variables were significantly associated with enrollment or starting the first session. Findings provide guidance for resource allocation decisions in larger scale DMHI implementations in healthcare settings.

Stability and spread: A novel method for quantifying transitions within multivariate binary time series data.

We present a novel method for quantifying transitions within multivariate binary time series data, using a sliding series of transition matrices, to derive metrics of stability and spread. We define stability as the trace of a transition matrix divided by the sum of all observed elements within that matrix. We define spread as the number of all non-zero cells in a transition matrix divided by the number of all possible cells in that matrix. We developed this method to allow investigation into high-dimensional, sparse data matrices for which existing binary time series methods are not designed. Results from 1728 simulations varying six parameters suggest that unique information is captured by both metrics, and that stability and spread values have a moderate inverse association. Further, simulations suggest that this method can be reliably applied to time series with as few as nine observations per person, where at least five consecutive observations construct each overlapping transition matrix, and at least four time series variables compose each transition matrix. A pre-registered application of this method using 4 weeks of ecological momentary assessment data (N = 110) showed that stability and spread in the use of 20 emotion regulation strategies predict next timepoint affect after accounting for affect and anxiety's auto-regressive and cross-lagged effects. Stability, but not spread, also predicted next timepoint anxiety. This method shows promise for meaningfully quantifying two unique aspects of switching behavior in multivariate binary time series data.

Building an emotion regulation recommender algorithm for socially anxious individuals using contextual bandits.

OBJECTIVES: Poor emotion regulation (ER) has been implicated in many mental illnesses, including social anxiety disorder. To work towards a scalable, low-cost intervention for improving ER, we developed a novel contextual recommender algorithm for ER strategies. DESIGN: N = 114 socially anxious participants were prompted via a mobile app up to six times daily for five weeks to report their emotional state, use of 19 different ER strategies (or no strategy), physical location, and social context. Information from passive sensors was also collected. METHODS: Given the large number of ER strategies, we used two different approaches for variable reduction: (1) grouping ER strategies into categories based on a prior meta-analysis, and (2) considering only the ten most frequently used strategies. For each approach, an algorithm that recommends strategies based on one's current context was compared with an algorithm that recommends ER strategies randomly, an algorithm that always recommends cognitive reappraisal, and the person's observed ER strategy use. Contextual bandits were used to predict the effectiveness of the strategies recommended by each policy. RESULTS: When strategies were grouped into categories, the contextual algorithm was not the best performing policy. However, when the top ten strategies were considered individually, the contextual algorithm outperformed all other policies. CONCLUSIONS: Grouping strategies into categories may obscure differences in their contextual effectiveness. Further, using strategies tailored to context is more effective than using cognitive reappraisal indiscriminately across all contexts. Future directions include deploying the contextual recommender algorithm as part of a just-in-time intervention to assess real-world efficacy. PRACTITIONER POINTS: Emotion regulation strategies vary in their effectiveness across different contexts. An algorithm that recommends emotion regulation strategies based on a person's current context may one day be used as an adjunct to treatment to help dysregulated individuals optimize their in-the-moment emotion regulation. Recommending flexible use of emotion regulation strategies across different contexts may be more effective than recommending cognitive reappraisal indiscriminately across all contexts.

The relationship between access to mental health resources and use of preferred effective mental health treatment.

OBJECTIVE: This study examined whether variables related to unequal access to mental health resources (including Black and Latinx racial-ethnic group membership, lower education level, and lower number of community-level treatment providers, and facilities) were associated with current mental health treatment use; and, whether these variables moderated the likelihood that individuals would receive their preferred effective treatment. METHODS: In a preregistered (osf.io/z28wr) study, 5626 individuals completed a mental health history form and measures of implicit and explicit beliefs about the effectiveness of therapy versus medication. RESULTS: Individuals with more (vs. less) education were more likely to report current treatment use. Individuals who were Black/Latinx (vs. non-Latinx White) or who lived in a community with fewer (vs. more) providers sometimes had a lower probability of accessing preferred effective treatment, though results varied across implicit and explicit measures. CONCLUSIONS: Findings highlight the need to increase access to mental health resources among marginalized groups.

Digital Mental Health Services: Moving From Promise to Results.

The papers in this special issue make a compelling case for the value of digital mental health services (DMHS; including technology-based interventions, assessments, and prevention programs) to help address some of the currently unmet needs in mental health care. At the same time, the papers highlight the work that needs to be accomplished for DMHS to fulfill their promise. We review the papers' contributions in terms of (a) the imperative to increase access to evidence-informed, high-quality care, especially for underserved populations, both in the United States and globally; (b) ways to use DMHS to improve the ways that clinical care is provided to make treatment provision more effective and efficient; and (c) the current state of the research on DMHS for emotional disorders. We then consider lessons learned and recommendations to move the field forward, such as increasing (and making transparent) the research base on DMHS, adopting regulatory standards for DMHS, attending carefully to training issues for DMHS and best practices for dissemination and implementation, designing specifically for digital platforms, and being intentional about efforts to reduce disparities regarding who benefits from DMHS.

Implicit and Explicit Beliefs About the Effectiveness of Psychotherapy vs. Medication: A Large-Scale Examination and Replication.

ABSTRACT: One exploratory study (N = 10,335) and one preregistered replication and extension study (N = 6648) evaluated implicit and explicit beliefs in the effectiveness of psychotherapy versus medication, and whether these beliefs vary as a function of demographics, mental health difficulties, and treatment experiences. Data were collected from a sample of visitors to a mental health research website who completed the Therapy vs. Medication Effectiveness Implicit Association Test (IAT). The IAT demonstrated evidence of convergent validity with two measures of explicit therapy versus medication effectiveness beliefs. Across both studies, individuals held greater implicit and explicit beliefs that therapy is more effective than medication, and individuals who were Black (versus all other races, excluding "other/unknown") and who had experienced past (versus current) mental health difficulties had stronger implicit and explicit beliefs in the effectiveness of therapy versus medication. More work is needed to understand how these differences in beliefs arise, as well as to evaluate the clinical utility of this novel measure.

Acceptability and Co-Development of an Online Cognitive Bias Modification Intervention for Emerging Adults With Hazardous Alcohol Use and Social Anxiety: A Mixed Methods Study.

BACKGROUND: Approach bias modification (ApBM) and interpretation bias modification (IBM) are two promising adjunct treatments for alcohol use and social anxiety, respectively. However, the acceptability of combining ApBM and IBM into one program for people who experience both of these disorders is unknown. The present study describes the codevelopment of a new, hybrid ApBM + IBM program and provides insight into the perceptions of acceptability from service providers and emerging adults. METHODS: Service providers (n = 14) and emerging adults aged 18 to 25 years with lived experience of hazardous alcohol use and heightened social anxiety (n = 15) were recruited via online advertisements and through existing networks. All participants were shown a beta version of the program and asked to complete qualitative and quantitative questions to ascertain feedback on the program's acceptability and suggestions for improvement. RESULTS: Themes emerged relating to the ApBM + IBM program's quality and usefulness, appropriateness, motivation and engagement, and potential clinical value. The program was well received and deemed acceptable for the target age group. It was rated particularly highly with regard to the overall quality and ease of use. Emerging adults had fewer suggestions for how the intervention might be revised; however, there were suggestions from both groups regarding the need for a compelling rationale at the outset of treatment and a suggestion to include a motivational interviewing and psychoeducational-based module prior to the first training session, to increase user buy-in and engagement. CONCLUSIONS: The current findings reflect positively on the acceptability of a hybrid ApBM + IBM for emerging adults with co-occurring hazardous alcohol use and social anxiety. Service providers and emerging adults identified a number of ways to improve the design and implementation of the program, which will likely improve adherence to, and outcomes of, the intervention when added as an adjunct to treatment as usual.

Threat and benign interpretation bias might not be a unidimensional construct.

The tendency for individuals to interpret ambiguous information in a threatening way is theorised to maintain anxiety disorders. Recent findings suggest that positive and negative interpretation biases may have unique effects. This study tested the relationships between threat and benign biases with state and trait anxiety and quality of life, and whether individual differences moderate these relationships. N = 699 individuals with elevated trait anxiety symptoms completed web-based measures of interpretation bias, trait anxiety, state anxiety, and quality of life. Results demonstrated that threat interpretations predicted state anxiety, trait anxiety, and quality of life. Benign interpretations also predicted quality of life. However, benign interpretations only weakly (or not at all) predicted state and trait anxiety. Individual differences (e.g. gender, race, ethnicity, age) did not moderate findings. Results emphasise the need to consider benign and threat biases separately, both in cognitive models of anxiety and experimental designs.

Relationships between trait emotion dysregulation and emotional experiences in daily life: an experience sampling study.

Few studies have examined how trait emotion dysregulation relates to momentary affective experiences and the emotion regulation (ER) strategies people use in daily life. In the current study, 112 college students completed a trait measure of emotion dysregulation and completed experience sampling and end-of-day surveys over a two- to three-week period, asking about their emotional experiences and ER strategy use. Participants completed a total of 3798 experience sampling (in-the-moment) and 995 nightly diary surveys. We examined the top 40% of each participant's reported instances of negative affect (to capture times when emotions more likely need regulation). Results indicated that a higher level of trait emotion dysregulation was associated with the following in-the-moment responses: (a) higher level of negative affect; (b) greater desire to change emotions; (c) more attempts to regulate emotion; (d) higher relative endorsements of avoidant (e.g. thought suppression) versus engagement (e.g. acceptance) ER strategy use; and (e) lower perceived effectiveness of ER. Further, individuals with a higher (vs. lower) level of trait emotion dysregulation were less able to identify emotions over the course of the day. Findings demonstrate how trait emotion dysregulation may predict emotional experiences and ER in daily life.

Do I really feel better? Effectiveness of emotion regulation strategies depends on the measure and social anxiety.

BACKGROUND: Effective emotion regulation (ER) is important to long-term healthy functioning, but little is known about what constitutes effective ER in the moment or how social anxiety symptoms and different strategies influence short-term effectiveness outcomes. METHODS: Intensive ecological momentary data from N = 124 college students illustrate how different ways of operationalizing ER effectiveness leads to different conclusions about the short-term effectiveness of different strategies in daily life. RESULTS: When effectiveness is operationalized as the degree to which participants judged that their ER attempts made them feel better, social anxiety severity was negatively associated with effectiveness, and avoidance-oriented strategies were judged to be less effective than engagement-oriented strategies. In contrast, when effectiveness is operationalized as the degree of change in self-reported affect following ER attempts, social anxiety severity was not related to effectiveness, and avoidance-oriented strategies were more effective than engagement-oriented strategies. Social anxiety and ER strategy type did not interact in either model, regardless of how effectiveness was measured. CONCLUSIONS: The study highlights discrepancies when examining two common but distinct ways of measuring the same overarching effectiveness construct, and raises intriguing questions about how forms of psychopathology that are intimately tied to emotion dysregulation, like social anxiety, moderate different ways of measuring the effectiveness of ER attempts.

Implicit Cognition and Psychopathology: Looking Back and Looking Forward.

Implicit cognitive processing is theorized to have a central role in many forms of psychopathology. In the current review, we focus on implicit associations, by which we mean evaluative representations in memory that are difficult to control and do not require conscious reflection to influence affect, cognition, or behavior. We consider definitional and measurement challenges before examining recent empirical evidence for these associations in anxiety, obsessive-compulsive, posttraumatic stress, depressive, and alcohol use disorders. This examination is framed by a brief review of the ways that prominent models of psychopathology represent biased implicit processing of disorder-relevant information. We consider to what extent models reflect more traditional automatic/implicit versus strategic/explicit dual-process perspectives or reflect more recent dynamical systems perspectives in which mental representations are iteratively reprocessed, evolving continuously. Finally, we consider the future research needed to better understand the interactive and temporal dynamics of implicit cognition in psychopathology.

How badly will I feel if you don't like me?: Social anxiety and predictions of future affect.

The current study investigated whether high and low socially anxious individuals would show differences in affective forecasting accuracy (i.e., the prediction of emotional states in response to future events) to positive versus negative social evaluation. High (n=94) and low (n=98) socially anxious participants gave a speech and were randomly assigned to receive a positive or negative evaluation. For affective forecasts made proximally (moments before the speech), those low in social anxiety overpredicted their affect to a greater extent to a negative evaluation versus a positive evaluation. In contrast, those high in social anxiety overpredicted their affect to positive and negative evaluations comparably, and failed to adjust their prediction for a future hypothetical negative evaluation - in effect, not learning from their prior forecasting error. Results suggest that affective forecasting biases deserve further study as a maintaining factor for social anxiety symptoms.

Evaluating Within-Person Change in Implicit Measures of Alcohol Associations: Increases in Alcohol Associations Predict Increases in Drinking Risk and Vice Versa.

AIMS: Implicit measures of alcohol associations (i.e. measures designed to assess associations that are fast/reflexive/impulsive) have received substantial research attention. Alcohol associations related to the self (drinking identity), the effects of alcohol (alcohol excite) and appetitive inclinations (alcohol approach) have been found to predict drinking cross-sectionally and over time. A critical next step in this line of research and the goal of this study is to evaluate whether increases in the strength of these associations predict increases in drinking and vice versa. These hypotheses were tested in a sample of first- and second-year US university students: a sample selected because this time period is associated with initiation and escalation of drinking, peak levels of alcohol consumption and severe alcohol-related negative consequences. SHORT SUMMARY: This study's purpose was to evaluate whether increases in the strength of alcohol associations with the self (drinking identity), excitement (alcohol excite) and approach (alcohol approach) as assessed by implicit measures predicted subsequent increases in drinking risk and vice versa using a longitudinal, university student sample. Results were consistent with hypotheses. METHODS: A sample of 506 students' (57% women) alcohol associations and alcohol consumption were assessed every 3 months over a 2-year period. Participants' consumption was converted to risk categories based on NIAAA's criteria: non-drinkers, low-risk drinkers and high-risk drinkers. A series of cross-lagged panel models tested whether changes in alcohol associations predicted subsequent change in drinking risk (and vice versa). RESULTS: Across all three measures of alcohol associations, increases in the strength of alcohol associations were associated with subsequent increases in drinking risk and vice versa. CONCLUSION: Results from this study indicate bi-directional relationships between increases in alcohol associations (drinking identity, alcohol excite and alcohol approach) and subsequent increases in drinking risk. Intervention and prevention efforts may benefit from targeting these associations.

Using Mobile Sensing to Test Clinical Models of Depression, Social Anxiety, State Affect, and Social Isolation Among College Students.

BACKGROUND: Research in psychology demonstrates a strong link between state affect (moment-to-moment experiences of positive or negative emotionality) and trait affect (eg, relatively enduring depression and social anxiety symptoms), and a tendency to withdraw (eg, spending time at home). However, existing work is based almost exclusively on static, self-reported descriptions of emotions and behavior that limit generalizability. Despite adoption of increasingly sophisticated research designs and technology (eg, mobile sensing using a global positioning system [GPS]), little research has integrated these seemingly disparate forms of data to improve understanding of how emotional experiences in everyday life are associated with time spent at home, and whether this is influenced by depression or social anxiety symptoms. OBJECTIVE: We hypothesized that more time spent at home would be associated with more negative and less positive affect. METHODS: We recruited 72 undergraduate participants from a southeast university in the United States. We assessed depression and social anxiety symptoms using self-report instruments at baseline. An app (Sensus) installed on participants' personal mobile phones repeatedly collected in situ self-reported state affect and GPS location data for up to 2 weeks. Time spent at home was a proxy for social isolation. RESULTS: We tested separate models examining the relations between state affect and time spent at home, with levels of depression and social anxiety as moderators. Models differed only in the temporal links examined. One model focused on associations between changes in affect and time spent at home within short, 4-hour time windows. The other 3 models focused on associations between mean-level affect within a day and time spent at home (1) the same day, (2) the following day, and (3) the previous day. Overall, we obtained many of the expected main effects (although there were some null effects), in which higher social anxiety was associated with more time or greater likelihood of spending time at home, and more negative or less positive affect was linked to longer homestay. Interactions indicated that, among individuals higher in social anxiety, higher negative affect and lower positive affect within a day was associated with greater likelihood of spending time at home the following day. CONCLUSIONS: Results demonstrate the feasibility and utility of modeling the relationship between affect and homestay using fine-grained GPS data. Although these findings must be replicated in a larger study and with clinical samples, they suggest that integrating repeated state affect assessments in situ with continuous GPS data can increase understanding of how actual homestay is related to affect in everyday life and to symptoms of anxiety and depression.

Using Advances From Cognitive Behavioral Models of Anxiety to Guide Treatment for Social Anxiety Disorder.

This case features an adult male with moderate social anxiety disorder and mild depressive symptoms who showed an initial positive response to an earlier experience of cognitive behavior therapy, but then relapsed when he started avoiding social situations again because of continuing beliefs that experiencing anxiety was unacceptable. His treatment at our clinic focused on shifting unhelpful thinking about the likelihood and consequences of becoming anxious and reengaging in avoided social situations so he could learn to tolerate negative affect and uncertainty. The treatment approach draws from cognitive behavioral models of social anxiety and highlights advances in clinical science, especially recent work on the causal role of interpretation biases (the tendency to assign negative or threatening meaning to ambiguous situations) in the maintenance and reduction of anxiety.

Age does not matter: Memory complaints are related to negative affect throughout adulthood.

OBJECTIVES: Memory complaints are present in adults of all ages but are only weakly related to objective memory deficits, raising the question of what their presence may indicate. In older adults, memory complaints are moderately related to negative affect, but there is little research examining this relationship in young and middle-aged adults. This study examined whether memory complaints and negative affect were similarly related across the adult lifespan and in adults with varying levels of objective memory performance. METHOD: The sample included 3798 healthy adults, aged 18 to 99, and was divided into five groups: young, middle-aged, young-old, old-old, and oldest-old adults. Participants completed questionnaire measures of memory complaints and negative affect (neuroticism and depressive and anxiety symptoms), in addition to lab measures of objective memory. RESULTS: Using structural equation models, we found that the relationship between memory complaints and negative affect was moderate in all the age groups, and there was no evidence for moderation by objective memory. CONCLUSION: For adults of all ages, perceived memory decline may be distressing and/or negative affect may lead to negative self-evaluations of memory.

Inhibitory control as a moderator of threat-related interference biases in social anxiety.

Prior findings are mixed regarding the presence and direction of threat-related interference biases in social anxiety. The current study examined general inhibitory control (IC), measured by the classic colour-word Stroop, as a moderator of the relationship between both threat interference biases [indexed by the emotional Stroop (e-Stroop)] and several social anxiety indicators. High socially anxious undergraduate students (N = 159) completed the emotional and colour-word Stroop tasks, followed by an anxiety-inducing speech task. Participants completed measures of trait social anxiety, state anxiety before and during the speech, negative task-interfering cognitions during the speech and overall self-evaluation of speech performance. Speech duration was used to measure behavioural avoidance. In line with hypotheses, IC moderated the relationship between e-Stroop bias and every anxiety indicator (with the exception of behavioural avoidance), such that greater social-threat interference was associated with higher anxiety among those with weak IC, whereas lesser social-threat interference was associated with higher anxiety among those with strong IC. Implications for the theory and treatment of threat interference biases in socially anxious individuals are discussed.

Implicit versus Explicit Rejection Self-Perceptions and Adolescents' Interpersonal Functioning.

We investigated associations between implicit and explicit self-perceptions of rejection with interpersonal functioning in close relationships. Adolescents (N=124) reported their explicit rejection self-perceptions on a questionnaire and completed the Implicit Association Test to assess their implicit rejection self-perceptions. After controlling for implicit self-perceptions, adolescents' explicit rejection self-perceptions were associated with the adolescents self-reporting more negative relationship quality with close friends and self-reporting more negative behaviors with romantic partners. After controlling for explicit self-perceptions, adolescents' implicit rejection self-perceptions were associated with their romantic partners reporting more negative relationship quality with them, and observations of adolescents displaying more negative behaviors with romantic partners. Implicit and explicit rejection self-perceptions uniquely explain individual differences in interpersonal behaviors.

A web-based examination of experiences with intrusive thoughts across the adult lifespan.

OBJECTIVES: Intrusive thoughts and images are common across the adult lifespan, but vary in their consequences. Understanding age-related experiences with intrusive thoughts is important for identifying risk and protective factors for intrusive thought problems across the adult lifespan. This study characterized age trajectories for six aspects of experiences with intrusive thoughts using Internet data collection. METHOD: Participants (N = 1427; ages 18-87) were randomly assigned to suppress (i.e. keep out of mind) or monitor an intrusive thought for one minute, and then later to monitor the thought for a second minute. Participants tracked thought recurrences during each thinking period, then reported their positive and negative affects following each thinking period, as well as their effort expended in suppressing the thought and perceived difficulty controlling the intrusive thought. Multilevel modeling and generalized estimating equations modeled the continuous relationships between age and each dependent variable. RESULTS: As expected, older age was associated with less decline in positive affect while engaging with an intrusive thought. Interestingly, older age was also associated with a sharper rise and fall of negative affect. Suppression effort increased linearly with age (though perceived difficulty did not). Finally, no age differences were found in either the frequency or duration of the thought's recurrence, adding to previous evidence that older adults function similarly to younger adults in their control of intrusive thoughts, despite certain age-related declines in cognitive functioning. CONCLUSION: These findings suggest a dissociation between age-related changes in emotional versus cognitive characteristics of engaging with intrusive thoughts.