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The compensation and capitalization models: A test of two approaches to individualizing the treatment of depression
Abstract
Despite long-standing calls for the individualization of treatments for depression, modest progress has been made in this effort. The primary objective of this study was to test two competing approaches to personalizing cognitive-behavioral treatment of depression (viz., capitalization and compensation). Thirty-four adults meeting criteria for Major Depressive Disorder (59% female, 85% Caucasian) were randomized to 16-weeks of cognitive-behavioral treatment in which strategies used were selected based on either the capitalization approach (treatment matched to relative strengths) or the compensation approach (treatment matched to relative deficits). Outcome was assessed with a composite measure of both self-report (i.e., Beck Depression Inventory) and observer-rated (i.e., Hamilton Rating Scale for Depression) depressive symptoms. Hierarchical linear modeling revealed a significant treatment approach by time interaction indicating a faster rate of symptom change for the capitalization approach compared to the compensation approach (d = .69, p = .03). Personalizing treatment to patients' relative strengths led to better outcome than treatment personalized to patients' relative deficits. If replicated, these findings would suggest a significant change in thinking about how therapists might best adapt cognitive-behavioral interventions for depression for particular patients.
... This value manifests in two models of change: compensatory and complementary [18]. The compensatory model suggests that patients with certain deficits may benefit more from treatments aimed at mitigating these deficits [19]. For instance, patients exhibiting low ET, as shown by their limited openness to new information, difficulty accepting support, or reluctance to explore their experiences in therapy, are likely to show greater positive changes when these specific vulnerabilities are addressed [20]. ...
... Conversely, the complementary model suggests that patients with relative strengths will benefit more from treatments that emphasize these strengths [19]. Therefore, patients with high ET, characterized by their openness to new information, robust ability to accept support, and readiness to explore their experiences in therapy, are well positioned to further enhance these qualities [21]. ...
... The findings supported this assumption, showing that higher ET at the start of treatment was associated with positive improvements in the patient's reported interpersonal difficulties, reduced avoidance in interactions with significant others, and an enhanced ability to establish a positive therapeutic alliance with the therapist. These findings align with the complementary model, which suggests "the rich get richer" [19], rather than the compensation model. In other words, our results support the notion that ET acts as a resilience factor [53]. ...
Epistemic trust (ET), the personal relevance we assign to knowledge received from others, is fundamental to effective therapy, yet its exact role remains unclear. Is ET a stable characteristic of the patient, or does it catalyze change during therapy? This study examines the constituents of ET in therapy and its related effects through three distinct lenses: a blended snapshot lens, a prognostic lens, and a lens focusing on state-like changes. Data from 116 psychodynamic therapy sessions reveal meaningful, though modest, correlations between ET and key components: patient attributes, therapist contributions, and the therapeutic relationship. These findings highlight ET’s multifaceted role and suggest that adjusting therapeutic approaches over time is essential to meet patients’ evolving needs.
... Overall, a differentiation has been made in psychotherapy research between capitalization (CAP)-oriented versus compensation (COMP)-oriented interventions. CAPs aim to draw on the person's already existing strengths (in a wide sense: action repertoire, resilience strategies, and external and internal resources), and COMPs identify dysfunctional maintenance factors of psychopathology and teach (respectively train) the person to use new strategies or build new behavior against relative deficits [14][15][16][17][18]. In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. ...
... CAPs aim to draw on the person's already existing strengths (in a wide sense: action repertoire, resilience strategies, and external and internal resources), and COMPs identify dysfunctional maintenance factors of psychopathology and teach (respectively train) the person to use new strategies or build new behavior against relative deficits [14][15][16][17][18]. In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. According to the current sparse research, there is no agreement on which of these 2 strategies should be pursued in psychotherapy [14,17,[19][20][21][22]. ...
... In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. According to the current sparse research, there is no agreement on which of these 2 strategies should be pursued in psychotherapy [14,17,[19][20][21][22]. ...
Background:
Only 11%-40% of those with a mental disorder in Germany receive treatment. In many cases, face-to-face psychotherapy is not available because of limited resources, such as an insufficient number of therapists in the area. New approaches to improve the German health care system are needed to counter chronification. Web-based interventions have been shown to be effective as stand-alone and add-on treatments to routine practice. Interventions designed for a wide range of mental disorders such as transdiagnostic interventions are needed to make treatment for mental disorders more accessible and thus shorten waiting times and mitigate the chronification of mental health problems. In general, interventions can be differentiated as having either a capitalization (CAP) focus-thus drawing on already existing strengths-or a compensation (COMP) focus-trying to compensate for deficits. Up to now, the effectiveness of transdiagnostic web-based interventions with either a CAP or a COMP focus has not yet been evaluated.
Objective:
This study is the first to examine the effectiveness of two transdiagnostic web-based interventions: (1) the activation of resilience and drawing on existing strengths (CAP: Res-Up!) and (2) the improvement of emotion regulation (COMP: REMOTION), compared with care as usual (CAU) in routine outpatient psychotherapy.
Methods:
Adults with at least 1 mental health disorder will be recruited at 4 outpatient centers in Germany. Participants will then be randomized equally into 1 of the 2 intervention groups Res-Up! (CAP) and REMOTION (COMP) or into the control group (CAU). Assessments will be made at baseline (T0), at 6 weeks after treatment start (T1), and at 12 weeks after treatment start (T2). A primary outcome will be symptom severity (Brief Symptom Inventory-18). Secondary outcomes will focus on emotion regulation and resilience.
Results:
Participant recruitment and data collection started in April 2020 and were ongoing as of July 2022. We expect participants to benefit more from the interventions than from the CAU control on the dimensions of symptom severity, resilience, and emotion regulation. Furthermore, we expect to find possible differences between CAP and COMP. The results of the study are expected in 2023.
Conclusions:
This randomized controlled trial will compare CAU with the transdiagnostic web-based interventions Res-Up! and REMOTION, and will thus inform future studies concerning the effectiveness of transdiagnostic web-based interventions in routine outpatient psychotherapy.
Trial registration:
ClinicalTrials.gov NCT04352010; https://clinicaltrials.gov/ct2/show/NCT04352010.
International registered report identifier (irrid):
DERR1-10.2196/41413.
... Overall, a differentiation has been made in psychotherapy research between capitalization (CAP)-oriented versus compensation (COMP)-oriented interventions. CAPs aim to draw on the person's already existing strengths (in a wide sense: action repertoire, resilience strategies, and external and internal resources), and COMPs identify dysfunctional maintenance factors of psychopathology and teach (respectively train) the person to use new strategies or build new behavior against relative deficits [14][15][16][17][18]. In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. ...
... CAPs aim to draw on the person's already existing strengths (in a wide sense: action repertoire, resilience strategies, and external and internal resources), and COMPs identify dysfunctional maintenance factors of psychopathology and teach (respectively train) the person to use new strategies or build new behavior against relative deficits [14][15][16][17][18]. In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. According to the current sparse research, there is no agreement on which of these 2 strategies should be pursued in psychotherapy [14,17,[19][20][21][22]. ...
... In an early study, Wingate et al [18] compared the outcomes of compensation versus capitalization in the treatment of suicidality in young adults, finding results favoring COMPs, whereas other studies find results favoring CAPs [14,17]. According to the current sparse research, there is no agreement on which of these 2 strategies should be pursued in psychotherapy [14,17,[19][20][21][22]. ...
BACKGROUND
Only 11-40% of those affected by a mental disorder in Germany receive treatment. New approaches to improve the German health care system are needed in order to counter chronification. Online-interventions have been shown to be effective as stand-alone as well as add-ons to routine practice. Interventions designed for a wide range of mental disorders such as transdiagnostic interventions are needed to make treatment for mental disorders more accessible and thus shorten waiting times. In general, interventions can be differentiated as having either a capitalization focus - thus drawing on already existing strengths (CAP) - or a compensation focus - trying to compensate for deficits (COMP). Up to now, the effectiveness of transdiagnostic online-interventions with either a CAP- or a COMP-focus has not yet been evaluated.
OBJECTIVE
This study is the first to examine the effectiveness of two online-interventions focusing on (1) the activation of resilience and drawing on existing strengths (CAP: Res-Up!) and (2) the improvement of emotion regulation (COMP: REMOTION), compared to care as usual in routine outpatient psychotherapy.
METHODS
Adults with at least one mental health disorder will be recruited at four outpatient centers in Germany. Assessments will be made at baseline (T0), at 6-weeks-posttreatment (T1) and at 12-weeks follow-up (T2). Primary outcome will be symptom severity (BSI-18). Secondary outcomes will focus on emotion regulation and resilience.
RESULTS
Participant recruitment and data collection started in April 2020 and are ongoing as of July 2022. Results of the study are expected in 2023.
CONCLUSIONS
This randomized controlled trial will compare care as usual with the transdiagnostic internet-interventions Res-Up! and REMOTION and will thus inform future studies concerning the effectiveness of transdiagnostic online interventions in routine outpatient psychotherapy.
CLINICALTRIAL
ClinicalTrials.gov NCT04352010, International Registered Report Identifier (IRRID)
... Beyond the TLSL distinction, it is of utmost importance to study the interaction between TL and SL components of the same construct, in this case ER. Previous research on matching TL maps with SL changes has demonstrated contrasting or congruent patterns, which can be explained by either the compensatory or capitalization model (Cheavens et al., 2012;Zilcha-Mano, 2021). While the compensatory model of treatments is likely to achieve greater success by focusing on addressing the deficits related to the disorder in patients, the capitalization model suggests that treatment effectiveness is enhanced when the focus is on harnessing and utilizing the patients' inherent strengths. ...
... Altogether, these results support the idea that addressing ER difficulties aligns with the assumptions of the capitalization or strength-based model (Cheavens et al., 2012). Specifically, patients with stronger TL ER and fewer interpersonal problems benefit the most from SL lower difficulties in ER. ...
Objective: The aim of this study was to disaggregate the between-patient and within-patient effects of emotion regulation (ER) on treatment outcome and explore relevant trait-like moderators of the within-patient effects. Method: Three hundred thirty-nine patients with heterogenous clinical conditions were admitted to psychotherapy at a clinical center. During the intake evaluation, patients completed the Inventory of Interpersonal Problems, the Outcome Questionnaire 30, and the State Difficulties of Emotion Regulation Scale. Subsequently, patients responded to the Outcome Questionnaire 30 and State Difficulties of Emotion Regulation Scale every session for the initial five sessions, followed by assessments every two sessions until the 15th session and then every four sessions until the end of treatment. Results: Multilevel models revealed significant between- and within-patient effects of ER on clinical distress. That is, patients with lower average levels of ER difficulties showed greater benefit from treatment, and lower ER difficulties over the course of treatment were associated with lower clinical distress. Furthermore, interactive models demonstrated that lower average levels of ER throughout treatment and fewer interpersonal problems at the beginning of treatment were associated with better treatment outcome. Conclusion: These findings provide evidence supporting the role of ER as a mechanism of change. The interaction between trait-like components and state-like fluctuations of ER suggests a capitalization model for the role of ER in psychotherapy.
... The exploratory moderation analysis showed that patients with the highest avoidance instrength scores at the outset showed the steepest reductions in anxiety. We did not have a specific a priori hypothesis regarding the direction of interactions, as either patients with the highest deficits at baseline (compensation model) or those with the least deficits (capitalisation model) might benefit most from treatment (Cheavens et al., 2012). Previous research with depressed individuals indicated that treatment approaches matched to individual strengths, not deficits, are more effective (Cheavens et al., 2012). ...
... We did not have a specific a priori hypothesis regarding the direction of interactions, as either patients with the highest deficits at baseline (compensation model) or those with the least deficits (capitalisation model) might benefit most from treatment (Cheavens et al., 2012). Previous research with depressed individuals indicated that treatment approaches matched to individual strengths, not deficits, are more effective (Cheavens et al., 2012). Our findings in patients with anxiety are more in line with the compensation model, suggesting that treatment is most effective for patients with stronger initial impairment in emotion regulation. ...
... 15 Similarly, better treatment response has also been associated in other research with poorer performance on the Wisconsin Card Sort Task, 16 in executive functioning, 17 and on a general neuropsychological battery. 18 Considering that CBT may also improve some aspects of neurocognitive functioning, 17 these findings are consistent with a compensation model of treatment prediction, 19,20 whereby individuals with deficits in several of these predictors are most likely to benefit. ...
... 19 In contrast, a capitalization model is one where individuals with certain strengths at baseline are most likely to benefit. 20 In PD, this would be illustrated by findings showing that having caregiver involvement in treatment (a strength) is associated with stronger CBT response. 14 Previous studies of PD and MDD using the RPLT found that MDD is associated with decreased optimal responding to reward in PD patients even when on dopamine replacement therapy and/or dopamine agonists, with relatively intact punishment learning. ...
Depression is highly comorbid among individuals with Parkinson’s Disease (PD), who often experience unique challenges to accessing and benefitting from empirically supported interventions like Cognitive Behavioral Therapy (CBT). Given the role of reward processing in both depression and PD, this study analyzed a subset (N = 25) of participants who participated in a pilot telemedicine intervention of PD-informed CBT, and also completed a Reward- and Punishment-Learning Task (RPLT) at baseline. At the conclusion of CBT, participants were categorized into treatment responders (n = 14) and non-responders (n = 11). Responders learned more optimally from negative rather than positive feedback on the RPLT, while this pattern was reversed in non-responders. Computational modeling suggested group differences in learning rate to negative feedback may drive the observed differences. Overall, the results suggest that a within-subject bias for punishment-based learning might help to predict response to CBT intervention for depression in those with PD.
Plain Language Summary Performance on a Computerized Task may predict which Parkinson’s Disease Patients benefit from Cognitive Behavioral Treatment of Clinical Depression
Why was the study done? Clinical depression regularly arises in individuals with Parkinson’s Disease (PD) due to the neurobiological changes with the onset and progression of the disease as well as the unique psychosocial difficulties associated with living with a chronic condition. Nonetheless, psychiatric disorders among individuals with PD are often underdiagnosed and likewise undertreated for a variety of reasons. The results of our study have implications about how to improve the accuracy and specificity of mental health treatment recommendations in the future to maximize benefits for individuals with PD, who often face additional barriers to accessing quality mental health treatment.
What did the researchers do? We explored whether performance on a computerized task called the Reward- and Punishment-Learning Task (RPLT) helped to predict response to Cognitive Behavioral Therapy (CBT) for depression better than other predictors identified in previous studies. Twenty-five individuals with PD and clinical depression that completed a 10-week telehealth CBT program were assessed for: Demographics (Age, gender, etc.); Clinical information (PD duration, mental health diagnoses, levels of anxiety/depression, etc.); Neurocognitive performance (Memory, processing speed, impulse control, etc.); and RPLT performance.
What did the researchers find? A total of 14 participants significantly benefitted from CBT treatment while 11 did not significantly benefit from treatment.There were no differences before treatment in the demographics, clinical information, and neurocognitive performance of those participants who ended up benefitting from the treatment versus those who did not.There were, however, differences before treatment in RPLT performance so that those individuals that benefitted from CBT seemed to learn better from negative feedback.
What do the findings mean? Our results suggest that the CBT program benefitted those PD patients with clinical depression that seemed to overall learn best from avoiding punishment rather than obtaining reward which was targeted in CBT by focusing on increasing engagement in rewarding activities. The Reward- and Punishment-Learning Task hence may be a useful tool to help predict treatment response and provide more individualized recommendations on how to best maximize the benefits of psychotherapy for individuals with PD that may struggle to connect to mental health care. Caution is recommended about interpretating these results beyond this study as the overall number of participants was small and the data for this study were collected as part of a previous study so there was no opportunity to include additional measurements of interest.
... When compared with interventions focused on deficits compensation (i.e. interventions that center on correction of patients' problems or deficits, see Cheavens et al. 2012), the ones focused on resources activation (i.e. interventions that center on change from the perspective of the competencies of the patients, see Cheavens et al. 2012 ) seem to have higher efficacy in both anxiety and mood disorders (for a review see Munder et al., 2019). ...
... interventions that center on correction of patients' problems or deficits, see Cheavens et al. 2012), the ones focused on resources activation (i.e. interventions that center on change from the perspective of the competencies of the patients, see Cheavens et al. 2012 ) seem to have higher efficacy in both anxiety and mood disorders (for a review see Munder et al., 2019). Congruently, positive psychology interventions presented beneficial effects on mental health in non-clinical populations (e.g., Bolier et al., 2013) and on clinical disorders (Carr et al., 2020). ...
At the beginning of the therapeutic process, clients frequently feel immersed in their problems, and demoralized, with a negative perspective of different areas of their lives. The clients´ discourse is specially focused on difficulties and previous ineffective attempts to overcome their problems. Even though positive aspects of the clients’ life continue to exist, such as resources and strengths, they have little visibility in the clients’ speech and, consequently, in the therapist’s assessment and intervention planning. Moreover, most psychotherapy models emphasize a focus on the deficits of the clients, centered on the correction of difficulties as a way to achieve mental health. In this context, we highlight the importance of integrating resources and strengths of the clients’ life in case assessment, clinical formulation, and treatment planning. This information can be collected in the assessment phase, but in order to make it explicit the relevance of this information we created a protocol designed for this purpose (Feedback Initiated Narrative Development Protocol [FIND]). The first component of FIND invites clients to reflect on aspects beyond their problem like their personal strengths, significant values, positive autobiographical episodes, and useful strategies that have been adopted in the past. This interview was largely influenced by narrative therapy and innovative moments research, and it provides information regarding clients’ resources that may be useful to psychotherapists from different approaches. In this paper, we presented a clinical case formulation considering resources evaluated with the FIND protocol.
... Of relevance, two electroencephalogram (EEG) studies in adults with anxiety and/or depression reported that blunted pre-treatment neural response to rewarding outcomes (but not the anticipation of rewards [50]) predicted greater depressive symptom improvement to CBT [50] and SSRI [51]. In contrast, other CBT studies [16,52,53], a trial of CBT vs. supportive therapy [54], as well as one study of the transdiagnostic Unified Protocol [55] yielded findings consistent with a capitalization model, such that patients who received a treatment matched to their relative strengths had the best outcomes. Notably, of the abovementioned studies that tested pre-treatment neural predictors of treatment outcome, all found evidence of neural response to rewarding outcomes predicting symptom improvement [16,50,51,54]. ...
... Namely, those individuals with a more intact neural response to rewards (relative to the other anhedonic adolescents in the sample) experienced better BA outcomes. These findings are generally consistent with several prior studies supporting a capitalization model [16,[52][53][54][55], but not with other research supporting a compensatory model [49][50][51]. However, given the substantial differences between the latter studies and the present study in sample (e.g., adults with depression or anxiety vs. anhedonic adolescents), imaging modality (e.g., EEG vs. fMRI), task (each used a different reward task) and intervention delivered (e.g., CBT, SSRI, or BA), it is very challenging to determine which study features contributed to the differences in findings. ...
Anhedonia is a cardinal characteristic of depression which predicts worse treatment outcome and is among the most common residual symptoms following treatment. Behavioral Activation (BA) has been shown to be an effective treatment for depressed adults, and more recently, depressed adolescents. Given its emphasis on systematically and gradually increasing exposure to and engagement with rewarding activities and experiences, BA may be a particularly effective intervention for adolescents experiencing anhedonia and associated reward system dysfunction. In the present study, anhedonic adolescents (AA; n = 39) received 12 weekly sessions of BA and completed a multimodal (i.e., neural, behavioral, and self-report [ecological momentary assessment]) assessment of reward function at pre-treatment and post-treatment (as well as weekly self-report assessments of anhedonia). Typically developing adolescents (TDA; n = 41) completed the same measures at corresponding timepoints. Multilevel models tested pre-treatment reward-related predictors of anhedonia improvement, as well as change in reward measures over the course of BA. Analyses revealed significant reductions in anhedonia following BA treatment. Enhanced pre-treatment neural (striatal) reward responsiveness predicted greater anhedonia improvement. In contrast, baseline self-report and behavioral reward measures did not predict treatment outcome. A group x time interaction revealed greater increases in both reward- and loss-related neural responsiveness among AA relative to TDA adolescents. Consistent with a capitalization (rather than compensatory) model, pre-treatment neural – but not self-report or behavioral – measures of relatively enhanced reward responsiveness predicted better BA outcome. In addition to alleviating anhedonia, successful BA may also increase neural sensitivity to affectively salient (e.g., reward- and loss-related) stimuli among anhedonic youth.
... Strengths use has been shown to mediate decreases in negative emotionality during a strengthsfocused CBT trial , suggesting that it may serve a mechanistic function in internalizing disorder symptom reduction (Cole & Maxwell, 2003). Furthermore, a randomized controlled trial for personalized depression treatment demonstrated that treatment matched to relative strengths outperformed treatment matched to relative deficits (Cheavens et al., 2012). Given the association of strengths use with well-being and symptom reduction, as well as its complementary role in psychotherapy, this construct aligns with efforts to target positive functioning during the UP. ...
Strengths use, the engagement of positive character traits in everyday contexts, is associated with both positive functioning and symptom reduction. The present study examined longitudinal relationships between strengths use and emotional disorder symptoms (anxiety, stress, and depression) during a randomized clinical trial of the Digital Unified Protocol, a transdiagnostic cognitive behavioral therapy. Participants (N = 120) completed assessments at four major time points during treatment and at 3-month follow-up. We specified three random-intercept cross-lagged panel model to capture within-person, bidirectional, time-lagged relationships between strengths use and anxiety, stress, and depression, respectively. Prospective increases in strengths use were associated with significant decreases in anxiety at all time points (β = −0.26 to −0.49), while prospective decreases in anxiety were associated with significant increases in strengths use at most time points (β = −0.25 to −0.36). Prospective increases in strengths use were associated with significant decreases in stress at most time points (β = −0.23 to −0.54), while prospective decreases in stress were associated with significant increases in strengths use at Week 4 (β = −0.21) and at follow-up (β = −0.41). Prospective increases in strengths use were associated with significant decreases in depression at Week 8 (β = −0.63) and at posttreatment (β = −0.67), while prospective decreases in depression were associated with significant increases in strengths use at most time points (β = −0.34 to −0.47). Clinical implications of findings are discussed, including the potential role of strengths use as a treatment target.
... The methodological heterogeneity of studies on resource activation suggests the existence of different pathways. For example, some studies activate resources by beginning treatment with a focus on clients' existing skills (e.g., cognitive strategies; Cheavens et al., 2012), whereas others have focused therapists' attention on their client's resources (e.g., Flückiger & Holtforth, 2008). Understanding when and how it may be beneficial to recruit clients' resources continues to raise several questions, so exploring clients' perceptions of resource use in treatment may provide new insights. ...
Objectives
Although psychotherapy research suggests that clients’ resources are related to positive outcomes, there is a lack of clinical tools available to consider their integration into psychotherapy. In this exploratory research, we studied the feasibility of a semi-structured interview to identify resources reported by clients at the onset of therapy and the relationship between resources and therapy outcomes.
Methods
Data consisted of interviews with 30 clients from a clinical trial, in which elicitation of resources and their relationship with the outcomes were the main study objectives.
Results
This interview was content analyzed and both adaptative resources and maladaptive resources (dysfunctional coping strategies) were identified. The association between the adaptive resources and the evolution of outcomes throughout treatment was analyzed. Time (i.e. sessions) and resources were negatively correlated with psychological distress. Moreover, resources positively influenced the impact of time on distress.
Conclusions
Clinicians should not take at face value resources that are self-reported, as they may reflect the maladaptive functioning of the client. The finding that clients with higher resources at onset have better outcomes points to the need to study how resources may be elicited effectively during therapy, and if this improves psychotherapy outcomes.
... Including and specifically targeting WTL in future (intervention) studies could contribute to a better understanding of the mechanisms underlying suicidal crises, in particular ambivalent states, and to derive effective psychological support. In clinical practice, including WTL in screening instruments could yield important information going beyond purely deficit-/symptom-oriented approaches, and as a therapeutic target, it could also be helpful as previous research has indicated better effectiveness of strengthsrather than weaknesses-focused interventions (Cheavens et al., 2012). Furthermore, the modeling of an interaction term is in line with the notion of diverse risk and protective factors working together/depending on one another that is inherent in modern theories of suicidal behavior. ...
Introduction
Suicidal ambivalence is increasingly understood as the result of the interplay of two conflicting motivational orientations, the wish to die (WTD) and wish to live (WTL). However, research is scarce regarding the nature of their relationship, their temporal structure, and their relevance in predicting suicidal desire.
Methods
Fifty psychosomatic/psychiatric inpatients (17 reporting suicide attempts) took part in an intensive longitudinal design with 10 signal‐contingent prompts per day over 10 days; assessing WTD, WTL, and suicidal desire. We calculated mean values and variability of WTD, WTL, suicidal ambivalence, and suicidal desire and tested mixed‐effects models of suicidal desire.
Results
The mean number of answered prompts was 40.98 (SD = 21.68). Repeated‐measures correlation of WTD and WTL was r = −0.60. Patients with a history of suicide attempts reported higher WTD, lower WTL, more suicidal ambivalence, stronger suicidal desire, and showed higher variability in all constructs. At the same assessment, WTD was the strongest statistical predictor of suicidal desire. Only WTL and the interaction of WTD and WTL predicted suicidal desire prospectively.
Conclusion
Wish to die and WTL are likely two distinct (although correlated) constructs that should not be reduced to a single ambivalence score. A stronger focus on WTL holds potential for suicide research and practice.
... 21 Mixed results supporting the capitalization and compensation models have been obtained for CBT and BA. [161][162][163] Considering the insufficient and contradictory evidence yielded by previous studies, increasing the benefit of BA treatments will require further research to elucidate the unique characteristics of individuals that determine whether a capitalization or compensation model is appropriate to apply to a specific individual. ...
Behavioral activation (BA) is a well-established method of evidence-based treatment for depression. There are clear links between the neural mechanisms underlying reward processing and BA treatment for depressive symptoms, including anhedonia; however, integrated interpretations of these two domains are lacking. Here we examine brain imaging studies involving BA treatments to investigate how changes in brain networks, including the reward networks, mediate the therapeutic effects of BA, and whether brain circuits are predictors of BA treatment responses. Increased activation of the prefrontal and subcortical regions associated with reward processing has been reported after BA treatment. Activation of these regions improves anhedonia. Conversely, some studies have found decreased activation of prefrontal regions after BA treatment in response to cognitive control stimuli in sad contexts, which indicates that the therapeutic mechanism of BA may involve disengagement from negative or sad contexts. Furthermore, the decrease in resting-state functional connectivity of the default-mode network after BA treatment appears to facilitate the ability to counteract depressive rumination, thereby promoting enjoyable and valuable activities. Conflicting results suggest that an intact neural response to rewards or defective reward functioning is predictive of the efficacy of BA treatments. Increasing the benefits of BA treatments requires identification of the unique individual characteristics determining which of these conflicting findings are relevant for the personalized treatment of each individual with depression.
... Furthermore, researchers speculate that older adults' emotion regulation strategies may align with interventions that focus on mindfulness (Geiger et al., 2016) as older adults report higher levels of mindfulness than younger adults (Hohaus & Spark, 2013;Mackenzie, Karaoylas, & Starzyk, 2018). An approach that focuses on mindfulness in older adults is in line with the capitalization model of intervention (Geiger et al., 2016), which suggests focusing on strengths (e.g., mindfulness) and is preferable to focusing on weaknesses (Cheavens, Strunk, Lazarus, & Goldstein, 2012;Wingate, van Orden, Joiner, Williams, & Rudd, 2005). Adding further support for its utility, mindfulness was the second most frequent mechanism of change in a review of therapeutic outcome research (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). ...
A lifetime of exposure to ageism may be internalized in older adults, and these ageist beliefs that are directed inwards can have severe consequences. However, research on reducing internalized ageism is scarce. To address this, we designed and implemented a six-week online process-based intervention to reduce internalized ageism and to assess its feasibility. The intervention utilized a process-based therapy approach targeting psychological, behavioral, and physiological pathways through which internalized ageism negatively impacts health, as specified by stereotype embodiment theory. Intervention components included education, acceptance and commitment therapy techniques, and attributional retraining. A total of 81 older adult participants participated in the feasibility study. Most participants rated each session and the overall program as very useful after each session (average program usefulness rating of 4.54/5). Participants also attributed a wide range of novel behaviors to this intervention and stated that they felt it changed their perspectives on ageism and/or internalized ageism. Results from this study provide a promising foundation from which to advance research on interventions that address internalized ageism - a problem that has severe consequences on the health and well-being of growing numbers of older adults globally.
... To better understand differential benefits from Project RISE among multiply-minoritized youth, we considered how the compensation and capitalization models of intervention response might describe the role of social support. The compensation model proposes that mental health treatments are most successful when they target a person's weaknesses, while the capitalization model asserts that treatments are optimized when targeting a person's strengths (Cheavens et al., 2012). If multiply-minoritized youth reporting high levels of perceived social support experience greater benefits from RISE, relative to youth reporting low levels of social support, then this is best explained by the capitalization model, which argues the increased availability of social support enhances post-SSI increases in identity pride due to the presence of stress-buffering relationships, which may decrease the internalization of identity-related stigma. ...
Objective. Leveraging data from a previously-conducted randomized trial, we examined whether Project RISE— a digital single-session intervention (SSI) focused on minority stress—was associated with equal improvements in levels of internalized stigma, identity pride, hopelessness, depression, and anxiety among White, sexual minority (SM), cisgender youth and racially and ethnically minoritized (REM), SM, and gender minority (GM) youth. We also tested whether higher levels of social support moderated outcomes.Methods. Participants randomly assigned to the intervention were included (n = 261 adolescents 13 to 16 years old; M age = 15; 51% REM youth; 68% transgender/gender-diverse). Two-way MANCOVAs were conducted to examine potential group differences outcomes across timepoints (i.e., post-intervention, two-week follow-up), between individuals holding multiple minoritized identities versus one. Moderation analyses were used to investigate whether social support moderated RISE outcomes. Results. Identifying with multiple minoritized identities was associated with higher levels of identity pride immediately post-intervention, and identifying as a GM was associated with slightly greater identity pride post-intervention. Youth who endorsed GM identities reported higher levels of hopelessness, depression, and anxiety at two-week follow-up, relative to cisgender youth. No other differences emerged.Conclusions. Youth with multiple minoritized identities, and especially those who identified as a GM, experienced significantly higher levels of identity pride following an online SSI targeting minority stress for LGBTQ+ teens. Results highlight the importance of applying an intersectional minority stress framework to online intervention design and considering social contexts (e.g., high versus low social support) when selecting treatments for youth with intersecting identities.
... Building upon these insights, it is reasonable to anticipate that individuals displaying greater plasticity or more dynamic reactivity in response to naturalistic stressors over extended durations in daily life might also exhibit enhanced plasticity with respect to learning gains during mental interventions. Such a view would align with empirical findings supporting the capitalization view of treatment gains, i.e., those with existing strengths are able to capitalize on them to reap greater benefits from a treatment [20,21]. Accordingly, the compensation versus capitalization model [21] suggests that an intervention could be more effective either (1) for individuals with the greatest difficulties in the areas targeted by the intervention (compensation) or (2) if it builds on the individual's existing strengths (capitalization). ...
Low-dose app-based contemplative interventions for mental health are increasingly popular, but heterogeneity in intervention responses indicates that a personalized approach is needed. We examined whether different longitudinal resilience–vulnerability trajectories, derived over the course of the COVID-19 pandemic, predicted differences in diverse mental health outcomes after mindfulness and socio-emotional dyadic online interventions. The CovSocial project comprised a longitudinal assessment (phase 1) and an open-label efficacy trial (phase 2). A community sample of 253 participants received 12 min daily app-based socio-emotional dyadic or mindfulness-based interventions, with weekly online coaching for 10 weeks. Before and after the intervention, participants completed validated self-report questionnaires assessing mental health. Stress reactivity profiles were derived from seven repeated assessments during the COVID-19 pandemic (January 2020 to March/April 2021) and were categorized into resilient (more plasticity) or vulnerable (less plasticity) stress recovery profiles. After both interventions, only individuals with resilient stress reactivity profiles showed significant improvements in depression symptomatology, trait anxiety, emotion regulation, and stress recovery. Those with vulnerable profiles did not show significant improvements in any outcome. Limitations of this study include the relatively small sample size and potential biases associated with participant dropout. Brief app-based mental interventions may be more beneficial for those with greater levels of stress resiliency and plasticity in response to stressors. More vulnerable individuals might require more intense and personalized intervention formats.
... In our routine care project, the focus is on clinician judgment and shared decision-making with patients based on their requests for modules. Beyond that, other tailoring strategies (Hornstein et al., 2023) could be explored in future studies and applications, such as basing the tailoring decisions on the strengths and weaknesses in the transdiagnostic processes to which the modules correspond (Cheavens et al., 2012;Sauer-Zavala et al., 2022), or on AI algorithms. ...
Background
Internet-based interventions offer a way to meet the high demand for psychological support. However, this setting also has disadvantages, such as the lack of personal contact and the limited ability to respond to crises. Blended care combines Internet-based interventions with face-to-face psychotherapy and merges the benefits of both settings. To ensure the uptake of blended care in routine care, Internet-based interventions need to be suitable for different therapeutic approaches and mental disorders.
Objective
This paper describes the participatory development process of the Internet-based intervention “TONI” using a common therapeutic language and content on various transdiagnostic topics to be integrated into routine outpatient psychotherapy.
Methods
To develop this intervention in a participatory manner, we followed the Integrate, Design, Assess, and Share (IDEAS) framework. In a multilevel development process, we used a combination of interviews, focus groups, and proofreading to optimally tailor online modules to routine outpatient psychotherapy. Building on well-established cognitive-behavioral online content, we included expert interviews with psychodynamic (n = 20) and systemic psychotherapists (n = 9) as well as focus groups with psychotherapists of different approaches (n = 10) and persons with lived experience of mental illness (PWLE; n = 10).
Results
We describe the development process of TONI step-by-step, outlining the specific requirements that therapists from different therapeutic approaches as well as PWLE have and how we implemented them in our intervention. This includes the content and specific exercises in the online modules, aspects of data protection, language, design, and usability.
Conclusion
Internet-based interventions that use a common therapeutic language and address therapeutic principles across different approaches have the potential to advance digitalization in psychotherapy. Involving psychotherapists and PWLE in intervention development may positively impact acceptance and usage in practice. This study shows how participatory intervention development involving both psychotherapists and PWLE can be carried out.
... Because the field of personality change interventions is still in its infancy and the mechanisms of change are largely unclear, the GCF model provides useful heuristic principles for intervention research. For example, depending on this model, different intervention routes and conditions can be contrasted, such as learning-related versus action-related intervention strategies Gómez-Penedo et al., 2023;Grosse Holtforth & Flückiger, 2012), or strengths-related versus problem-related intervention strategies Cheavens et al., 2012;Flückiger et al., 2021), to examine the unique effects of intervention routes based on individual general factors. Moreover, a key assumption of the GCF model is that realizing all factors should maximize intervention effects (Allemand & Flückiger, 2017, 2022. ...
The mechanisms of change underlying the effectiveness of personality change interventions are largely unclear. In this study, we used data from a three-month digital intervention with an intensive longitudinal design to test whether a greater realization of general change factors is partly responsible for personality change. Participants (N = 679, 53.0% female; age: M = 25.3 years, SD = 7.1) seeking to increase either Emotional Stability, Conscientiousness, or Extraversion provided self-ratings on their weekly personality states and the three generic change factors of strengths, insights, and behavioral practice. We found a single-factor structure of change factors within and between individuals. Results showed within-person increases in Emotional Stability, Extraversion, and Conscientiousness states as well as increases in change factors across the intervention. Changes in personality states were coupled with changes in generic change factors. Finally, the results provide initial support for the hypothesis that the realization of general change factors is partly responsible for the effects of the intervention. Within-person increases in the change factors were associated with subsequent increases in Extraversion and Emotional Stability states during the following week. The present findings highlight the need to better understand how and why people change in personality as a result of interventions. Plain language summary: Recent studies have shown that it is possible to change personality traits through psychological interventions. However, the mechanisms of change are largely unclear. The present study therefore examined whether targeting supportive (strengths), learning (insight) and action (behavioral practice) factors through intervention contributes to personality change. Our results provide initial evidence that these general change mechanisms are partly responsible for personality changes.
... MBCT is an evidencebased treatment for major depressive disorder (MDD) that combines elements of cognitive behavioral therapy and meditative practices and is both effective in reducing relapse rates and (residual) depressive symptoms (Goldberg et al., 2019). Based on a compensation model (Cheavens et al., 2012), it could be argued that in particular individuals with lower levels of mindfulness skills at baseline will profit from MBIs such as MBCT because an existent deficiency is targeted. Based on a capitalization model, on the other hand, it could be argued that in particular individuals with higher baseline levels of mindfulness skills will profit because more mindful people may find the mindfulness practice easier or more comfortable, and may persist longer at practicing (Shapiro et al., 2011). ...
Mindfulness is a multifaceted concept which might be best captured by person-centered profiles rather than by variable-centered assessment of its subcomponents. Patients with different mindfulness profiles may vary in mental health status and might experience differential clinical outcomes of Mindfulness-Based Cognitive Therapy (MBCT). We therefore aimed to assess the relationship between mindfulness profiles and mental health in patients with major depressive disorder (MDD) and to examine whether mindfulness profiles are predictive for MBCT-induced changes in mental health.
Latent profile analysis (LPA), a method used to identify hidden subgroups of individuals within a population, was performed on pre-MBCT subscale scores of the Five Facet Mindfulness Questionnaire in patients with current or remitted MDD (n=754). Equality of means of pre-MBCT, post-MBCT, and residualized change scores of several mental health measures across the latent profiles was tested.
LPA identified four distinct mindfulness profiles. Three profiles were similar to previously identified profiles in another MDD sample (“very low mindfulness,” “high mindfulness,” “non-judgmentally aware”) and one profile was similar to that identified in non-clinical populations (“judgmentally observing”). The “high mindfulness” subgroup scored best, the “very low mindfulness” worst, and the other subgroups intermediate on mental health in terms of depressive symptoms, worry, overall functional impairment, and self-compassion. Mindfulness profiles were not predictive of MBCT-induced changes in mental health.
Mindfulness profiles were differentially related to mental health, but were not predictive of treatment outcome. Future research would benefit from longitudinal assessment of latent mindfulness profiles to examine whether a patient’s profile changes after MBCT and whether hypothesized change in profile would be related to treatment outcome.
This study was not preregistered.
... In fact, CBT therapists used more words relating to positive emotions. This might be due to aspects of CBT not included in the specific features outlined by Blagys and Hilsenroth (2002) such as fostering patients' strengths and resources, social reinforcement, and the elicitation of positive expectations (Cheavens et al., 2012;Flückiger & Grosse Holtforth, 2008;Raue & Goldfried, 1994;Willutzki et al., 2012). In line with that, CBT for eating disorders typically involves resource activation, enhancement of self-esteem, and euthymic methods, at least as optional modules (Legenbauer & Vocks, 2014). ...
It is generally assumed that psychodynamic therapy and cognitive behavioral therapy (CBT) differ in terms of applied techniques and processes. To date, however, little is known about whether and how such differences can actually be observed at a basic linguistic level and in what the two treatment approaches differ most strongly (i.e., how psychodynamic and CBT therapists differ in what they actually say word-by-word in therapy sessions). Building on theoretical models and previous research that used observer ratings, we formulated specific hypotheses regarding which word categories psychodynamic and CBT therapists who treat patients with an eating disorder should differ in. To investigate these hypotheses, we used verbatim transcripts from 297 therapy sessions of a randomized controlled trial in which patients with anorexia nervosa (n = 88) received either focal psychodynamic therapy (FPT) or CBT. These transcripts were then examined using computerized quantitative text analysis. In line with our hypotheses, we found that CBT therapists overall spoke more than their FPT counterparts and that they used more words related to eating. Also in line with our hypotheses, FPT therapists used more words related to social processes. Contrary to our expectations, CBT therapists did not show a stronger focus on the future but talked more about emotions than FPT therapists. The latter effect, however, appears to be driven by a stronger focus on positive emotions. These findings suggest that computerized quantitative text analysis can differentiate meaningful language characteristics of CBT and FPT on spoken-word level and that it holds potential as a tool for researchers and therapists.
... The selection of emotion regulation skills is based on client preferences, needs, and strengths. Research on depression indicates that the selection of skills that strengthen existing competencies rather than fill a gap (compensatory) results in a greater decrease in symptoms (Cheavens et al., 2012). This may be because emphasizing strengths may enhance mastery and positive self-regard, both of which are low among trauma-exposed individuals. ...
Background:
Complex PTSD is a recent addition to the ICD-11 diagnostic system.
Aims:
This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of complex posttraumatic stress disorder. SNT balances interventions that address current-day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man.
Discussion:
The case analysis describes the ways in which SNT is relevant and effective in addressing the client's mulitple concerns. The skills work helped the client effectively manage ongoing minority stress, discrimination, and micro-aggressions related to his identity as a gay man. Review and re-appraisal of his traumatic memories, which focused on the sudden death of his partner from AIDS along with discussion of events from his childhood that shaped his reactions to this loss, allowed the client to create a more integrated sense of self as well as a more compassionate view of himself. Implications regarding the relevance of SNT for sexual and gender minority individuals are discussed.
... The processes of problem-coping experiences and resource activation were selected considering that therapists should balance their work between addressing and managing current problems and difficulties (problem coping), and also building and utilizing patients' strengths and resources (Cheavens et al., 2012;Gassmann & Grawe, 2006). Therapists should consider that problem-coping experiences can lead to resource activation and vice-versa. ...
Objective: Psychotherapy can be improved by integrating the study of mediators (how it works) and moderators (for whom it works). To demonstrate this integration, we studied the relationship between resource activation, problem coping experiences and symptoms in cognitive-behavior therapy (CBT) for depression, to obtain preliminary insights on causal inference (which process leads to symptom improvement?) and prediction (which one for whom?). Method: A sample of 715 patients with depression who received CBT was analyzed. Hierarchical Bayesian continuous time dynamic modeling was used to study the temporal dynamics between the variables analyzed within the first ten sessions. Depression and self-efficacy at baseline were examined as predictors of these dynamics. Results: There were significant cross-effects between the processes studied. Under typical assumptions, resource activation had a significant effect on symptom improvement. Problem-coping experience had a significant effect on resource activation. Depression and self-efficacy moderated these effects. However, when system noise was considered, these effects may be affected by other processes. Conclusion: Resource activation was strongly associated with symptom improvement. To the extent of inferring causality, for patients with mild-moderate depression and high self-efficacy, promoting resource activation can be recommended. For patients with severe depression and low self-efficacy, promoting problem-coping experiences can be recommended.
... Similarly, given evidence that CBT increases activation in brain regions involved in emotion regulation in adults (Roiser et al., 2012;Rubin-Falcone et al., 2018), adolescents with difficulties regulating sad and dysphoric emotions may similarly benefit most from CBT. At the same time, there is also evidence that interventions can be enhanced by building on individual strengths (Cheavens et al., 2012), suggesting that adolescents who begin CBT with relatively strong reward responsiveness and emotion regulation skills may show the most improvement (e.g., Webb et al., 2021). ...
Earlier depression onsets are associated with more debilitating courses and poorer life quality, highlighting the importance of effective early intervention. Many youths fail to improve with evidence-based treatments for depression, likely due in part to heterogeneity within the disorder. Multi-method assessment of individual differences in positive and negative emotion processing could improve predictions of treatment outcomes. The current study examined self-report and neurophysiological measures of reward responsiveness and emotion regulation as predictors of response to cognitive-behavioral therapy (CBT). Adolescents (14-18 years) with depression (N = 70) completed monetary reward and emotion regulation tasks while electroencephalogram (EEG) was recorded, and self-report measures of reward responsiveness, emotion regulation, and depressive symptoms at intake. Adolescents then completed a 16-session group CBT program, with depressive symptoms and clinician-rated improvement assessed across treatment. Lower reward positivity amplitudes, reflecting reduced neural reward responsiveness, predicted lower depressive symptoms with treatment. Larger late positive potential residuals during reappraisal, potentially reflecting difficulty with emotion regulation, predicted greater clinician-rated improvement. Self-report measures were not significant predictors. Results support the clinical utility of EEG measures, with impairments in positive and negative emotion processing predicting greater change with interventions that target these processes.
... In our routine care project, the focus is on clinician judgment and shared decision-making with patients based on their requests for modules. Beyond that, other tailoring strategies (Hornstein et al., 2023) could be explored in future studies and applications, such as basing the tailoring decisions on the strengths and weaknesses in the transdiagnostic processes to which the modules correspond (Cheavens et al., 2012;Sauer-Zavala et al., 2022), or on AI algorithms. ...
Background: Internet-based interventions offer a way to meet the high demand for psychological support. However, this setting also has disadvantages, such as the lack of personal contact and the limited ability to respond to crises. Blended care combines Internet-based interventions with face-to-face psychotherapy and merges the benefits of both settings. To ensure the uptake of blended care in routine care, Internet-based interventions need to be suitable for different therapeutic approaches and mental disorders.Objective: This paper describes the participatory development process of the Internet-based intervention “TONI” using a common therapeutic language and content on various transdiagnostic topics to be integrated into routine outpatient psychotherapy.Methods: To develop this intervention in a participatory manner, we followed the Integrate, Design, Assess, and Share (IDEAS) framework. In a multilevel development process, we used a combination of interviews, focus groups, and proofreading to optimally tailor online modules to routine outpatient psychotherapy. Building on well-established cognitive-behavioral online content, we included expert interviews with psychodynamic (n = 20) and systemic psychotherapists (n = 9) as well as focus groups with psychotherapists of different approaches (n = 10) and persons with lived experience of mental illness (PWLE; n = 10).Results: We describe the development process of TONI step-by-step, outlining the specific requirements that therapists from different therapeutic approaches as well as PWLE have and how we implemented them in our intervention. This includes the content and specific exercises in the online modules, aspects of data protection, language, design, and usability.Conclusion: Online interventions that use a common therapeutic language and address therapeutic principles across different approaches have the potential to advance digitalization in psychotherapy. Involving psychotherapists and PWLE in intervention development may positively impact acceptance and usage in practice. This study shows how participatory intervention development involving both psychotherapists and PWLE can be carried out.
... A clinical study focusing on individuals diagnosed with major depressive disorder had therapists focus on building strengths or remediating deficits in the cognitivebehavioral treatment context. The group randomly assigned to building strengths led to better outcomes and quicker recovery than the group focused on deficit-reduction (Cheavens et al., 2012). ...
Purpose
This paper aims to examine how character strengths have an important dual role in mental health in both promoting well-being and mental wellness and also in reducing symptoms and suffering. While there are many studies that have touched upon variables that character strengths can enhance for mental well-being or reduce for suffering, the author actually knows very little about how character strengths might relate to or impact mental health.
Design/methodology/approach
A large-scale study of 12,050 individuals was conducted to explore the self-perceived character strengths that are most helpful for mental health, for handling physical adversity, for handling social adversity and for fostering psychological well-being.
Findings
Some character strengths showed a general effect – showing a strong perceived impact across multiple domains – such as love, perspective, kindness, hope, humor and curiosity. Other character strengths showed a specific effect in that there was a strong perceived impact in one domain, such as perseverance and self-regulation for physical health, spirituality and social intelligence for social health and creativity for mental health. A strength-based approach to understanding and managing emotions was substantially more preferred than cognitive or behavioral approaches. Other findings examined the character strengths most desired to be improved upon for mental health.
Research limitations/implications
The research strategy was cross-sectional, thereby causality cannot be determined. Because of the large sample size, researchers are encouraged to consider examining the findings in intervention studies.
Practical implications
This study indicates that character strengths are highly relevant for mental health, all 24 character strengths are possible pathways to impact mental health (some more than others) and individuals can readily connect ways they can use their character strengths to positively improve their well-being and manage their suffering.
Social implications
Character strengths and their substantial positive potential provide an avenue for public impact on a large scale.
Originality/value
To the best of the author’s knowledge, this is the first known study to directly examine multiple intersections among mental health and character strengths in a large sample.
... Second, providers in individual sessions may use this information to identify which maladaptive strategies patients are using most frequently, so they can prioritize their reduction. Third, providers in individual sessions may focus less on helping patients use a range of adaptive skills and instead capitalize on a limited number of adaptive skills the patient is relatively better at to target decreasing their most frequent maladaptive strategies (Cheavens, Strunk, Lazarus, & Goldstein, 2012). Because patients will learn the full range of adaptive skills in group skills training, individual sessions could be more focused and tailored to the patient's goals. ...
It is well-established that participation in dialectical behavior therapy (DBT) results in patients using adaptive coping strategies more frequently. Although coping skill instruction may be necessary to promote decreases in symptoms and behavioral targets in DBT, it is unclear if the frequency with which patients use adaptive coping skills leads to these outcomes. Alternatively, it is possible that DBT also leads patients to use maladaptive strategies less frequently and that these reductions more consistently predict improvements in treatment. We recruited 87 participants with elevated emotion dysregulation (Mage = 30.56; 83.9% female; 75.9% White) to participate in a 6-month course of full-model DBT delivered by advanced graduate students. Participants completed measures of adaptive and maladaptive strategy use, emotion dysregulation, interpersonal problems, distress tolerance, and mindfulness at baseline and after three DBT skills training modules. Both within- and between-person maladaptive strategy use significantly predicted module-to-module changes in all outcomes whereas adaptive strategy use significantly predicted changes in emotion dysregulation and distress tolerance, although the size of these effects did not significantly differ between adaptive and maladaptive strategy use. We discuss the limitations and implications of these results for optimizing DBT.
... Second, providers in individual sessions may use this information to identify which maladaptive strategies patients are using most frequently, so they can prioritize their reduction. Third, providers in individual sessions may focus less on helping patients use a range of adaptive skills and instead capitalize on a limited number of adaptive skills the patient is relatively better at to target decreasing their most frequent maladaptive strategies (Cheavens, Strunk, Lazarus, & Goldstein, 2012). Because patients will learn the full range of adaptive skills in group skills training, individual sessions could be more focused and tailored to the patient's goals. ...
It is well-established that participation in dialectical behavior therapy (DBT) results in patients using adaptive coping strategies more frequently. Although coping skill instruction may be necessary to promote decreases in symptoms and behavioral targets in DBT, it is unclear if the frequency with which patients use adaptive coping skills leads to these outcomes. Alternatively, it is possible that DBT also leads patients to use maladaptive strategies less frequently and that these reductions more consistently predict improvements in treatment. We recruited 87 participants with elevated emotion dysregulation (Mage = 30.56; 83.9% female; 75.9% White) to participate in a 6-month course of full-model DBT delivered by advanced graduate students. Participants completed measures of adaptive and maladaptive strategy use, emotion dysregulation, interpersonal problems, distress tolerance, and mindfulness at baseline and after three DBT skills training modules. Both within- and between-person maladaptive strategy use significantly predicted module-to-module changes in all outcomes whereas adaptive strategy use significantly predicted changes in emotion dysregulation and distress tolerance, although the size of these effects did not significantly differ between adaptive and maladaptive strategy use. We discuss the limitations and implications of these results for optimizing DBT.
... On the one hand, individuals with relative deficits in domains targeted by ESTEEM, such as social isolation or difficulties with emotion regulation, may have a preferential response to the intervention. On the other hand, CBTs for depression sometimes yield stronger effects when building on an individual's strengths rather than focusing on areas of deficit (Cheavens et al., 2012;Lemmens et al., 2020;Murphy et al., 2021). Therefore, deficits in these treatment facilitators might be associated with less benefit upon receiving ESTEEM. ...
Objective:
Lesbian, gay, bisexual, and queer (LGBQ)-affirmative cognitive behavioral therapy (CBT) focused on minority stress processes can address gay and bisexual men's transdiagnostic mental and behavioral health concerns. Identifying moderators of treatment outcomes may inform the mechanisms of LGBQ-affirmative CBT and subpopulations who may derive particular benefit.
Method:
Data were from a clinical trial in which gay and bisexual men with mental and behavioral health concerns were randomized to receive Effective Skills to Empower Effective Men (ESTEEM; an LGBQ-affirmative transdiagnostic CBT; n = 100) or one of two control conditions (n = 154): LGBQ-affirmative community mental health treatment (CMHT) or HIV counseling and testing (HCT). The preregistered outcome was a comorbidity index of depression, anxiety, alcohol/drug problems, and human immunodeficiency virus (HIV) transmission risk behavior at 8-month follow-up (i.e., 4 months postintervention). A two-step exploratory machine learning process was employed for 20 theoretically informed baseline variables identified by study therapists as potential moderators of ESTEEM efficacy. Potential moderators included demographic factors, pretreatment comorbidities, clinical facilitators, and minority stress factors.
Results:
Racial/ethnic minority identification, namely as Black or Latino, was the only statistically significant moderator of treatment efficacy (B = -3.23, 95% CI [-5.03, -1.64]), t(197) = -3.88, p < .001. Racially/ethnically minoritized recipients (d = -0.71, p < .001), but not White/non-Latino recipients (d = 0.22, p = .391), had greater reductions in comorbidity index scores in ESTEEM compared to the control conditions. This moderation was driven by improvements in anxiety and alcohol/drug use problems.
Discussion:
Black and Latino gay and bisexual men experiencing comorbid mental and behavioral health risks might particularly benefit from a minority stress-focused LGBQ-affirmative CBT. Future research should identify mechanisms for this moderation to inform targeted treatment delivery and dissemination. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... In the current investigation, we hypothesized that the mechanism underlying the greater response to PTSD treatment of individuals with larger pretreatment hippocampal volume is an additional increase in hippocampal volume during treatment. This hypothesis is based on theories arguing for the benefit of capitalizing on strengths-the "rich get richer" phenomenon (20): individuals with already larger pretreatment hippocampal volume may benefit most from leveraging this strength, gaining further increase in hippocampal volume during treatment and therefore showing better treatment outcomes. The underlying mechanism may be extinction learning, which is key to successful PTSD treatment (21). ...
Background
The hippocampus plays an important role in the pathophysiology of posttraumatic stress disorder (PTSD) and its prognosis. Accumulating findings suggest that individuals with larger pretreatment hippocampal volume are more likely to benefit from PTSD treatment, but the mechanism underlying this effect is unknown. We investigated whether further increase in hippocampal volume during treatment explains the better prognosis of individuals with greater pretreatment hippocampal volume.
Methods
We collected structural magnetic resonance imagesfrom patients with PTSD before and after treatment. We examined whether larger hippocampal volume moderates the effect of increased hippocampal volume during treatment on symptom reduction. Given the relatively small sample sizes of treatment studies with pre- and posttreatment magnetic resonance imaging, we focused on effect sizes and sought to replicate findings in an external sample. We tested our hypothesis in study 1 (N = 38; prolonged exposure therapy) and then tested whether the results could be externally replicated in study 2 (N = 20; ketamine infusion followed by exposure therapy).
Results
Findings from study 1 revealed that increased right hippocampal volume during treatment was associated with greater PTSD symptom reduction only in patients with greater pretreatment right hippocampal volume (p = .03; η² = 0.13, a large effect). Findings were partially replicated in study 2 for depressive symptoms (p = .034; η² = 0.25, a very large effect) and for PTSD symptoms (p = .15; η² = 0.15, a large effect).
Conclusions
Elucidating increased hippocampal volume as one of the neural mechanisms predictive of therapeutic outcome for individuals with larger pretreatment hippocampal volume may help identify clinical targets for this subgroup.
... The selection of emotion regulation skills is based on client preferences, needs and strengths. Research on depression indicates that the selection of skills that strengthen existing competencies rather than fill a gap (compensatory) result in greater decrease in symptoms (Cheavens et al., 2012). This may be because emphasizing strengths may enhance of mastery and positive self-regard, both of which are low among trauma-exposed individuals. ...
Complex PTSD (CPTSD) is a new diagnosis in the World Health Organization (WHO)’s International Classification of Diseases (ICD-11). This case study describes the delivery of Skills Training in Affective and Interpersonal Regulation and Narrative Therapy (SNT), a flexible, multi-component therapy that addresses the symptoms of CPTSD. SNT balances interventions that address current day stressors with those that reappraise the meaning of traumatic past events. This paper outlines 16 sessions of SNT with a 55-year-old gay man. The treatment introduces client tailored coping skills for current minority stress, discrimination and micro-aggressions as well as trauma-focused interventions regarding events from his childhood and the death of his partner and many members of his community due to the AIDS epidemic. Qualitative and quantitative outcomes are summarized. Implications regarding the relevance of SNT for sexual and gender minority (SGM) individuals is discussed.
... We planned to test the skills core to our two strategies as potential moderators: CBT skills and positive thinking skills. Although findings have been mixed, there is some evidence suggesting that participants may respond more positively to interventions that harness a pre-existing skill (Cheavens et al., 2012). Given the mixed findings, we did not hypothesize a direction for the two potential moderators we planned to test. ...
Objective:
Despite its considerable potential, psychotherapy research has made limited use of small-scale experimental study designs to test intervention components. This study employs such a design to test the immediate effects on emotional experience of two approaches to changing negative thoughts, cognitive restructuring and fostering positive thinking. Cognitive restructuring draws on the strategies core to cognitive behavioral therapies. Fostering positive thinking has also received attention, though less so as a psychological intervention.
Method:
We tested the benefits of these strategies over a brief interval by randomizing 230 participants to complete a worksheet introducing one of the two strategies. Participants reported their skills prior to exposure to these worksheets and affect was assessed immediately prior to and following use of worksheets.
Results:
Participants' negative affect reduced following both strategies. Conditions did not differ significantly in affect change. Analysis of potential moderators showed that, among those with higher levels of cognitive behavioral therapy skills, the positive thinking condition produced greater gains in positive affect than the cognitive restructuring condition.
Conclusions:
These results indicate that both forms of brief interventions promote reductions in negative affect. Positive thinking interventions, which are not focused on the accuracy of one's thinking, appear to be particularly effective in promoting positive affect.
... Direct comparisons of mindfulness and distraction coping strategies have largely been limited to controlled laboratory settings, limiting the generalizability of these findings. The extent to which mindfulness or distraction are effective as coping mechanisms likely depends on the environmental context at a given moment [26,27]. Additionally, though many therapeutic programs teach strategies for coping with cravings [18,28], these require individuals to learn a strategy at a time when cravings may not be present or distressing, then implement the strategy later when they are experiencing uncomfortable or distressing levels of craving. ...
Background
Cannabis misuse in young adults is a major public health concern. An important predictor of continued use is cannabis craving. Due to the time-varying nature of cravings, brief momentary interventions delivered while cravings are elevated may improve the use of strategies to cope with cravings and reduce cannabis use.
Objective
The goal of this manuscript is to describe a formative study to develop coping strategy messages for use in a subsequent intervention.
Methods
Young adults (aged 19-25 years; n=20) who reported using cannabis >10 of the past 30 days recruited via social media participated in this formative study. Participants rated an initial set of 15 mindfulness and 15 distraction coping strategies on a scale from 1 to 4 (very low degree to very high degree) for clarity, usefulness, and tone. They also provided comments about the content.
Results
Participants found the initial distraction messages slightly clearer than mindfulness (mean 3.5, SD 0.4 and mean 3.4, SD 0.4, respectively), both were comparable in tone (mean 3.2, SD 0.5 and mean 3.2, SD 0.4, respectively), and mindfulness messages were more useful than distraction (mean 3.0, SD 0.5 and mean 2.8, SD 0.6, respectively). Of the 30 messages, 29 received a rating of very low or low (<2) on any domain by >3 participants or received a comment suggesting a change. We revised all these messages based on this feedback, and the participants rated the revised messages approximately 2 weeks later. Participants earned US 20 for the second survey. The ratings improved on usefulness (especially the distraction items) with very little change in clarity and tone. The top 10 messages of each coping type (mindfulness and distraction) were identified by overall average rating (collapsed across all 3 dimensions: all rated >3.0). The final items were comparable in clarity (distraction mean 3.6, SD 0.4; mindfulness mean 3.6, SD 0.4), tone (distraction mean 3.4, SD 0.4; mindfulness mean 3.4, SD 0.4), and usefulness (distraction mean 3.1, SD 0.5; mindfulness mean 3.2, SD 0.5).
Conclusions
The inclusion of end users in the formative process of developing these messages was valuable and resulted in improvements to the content of the messages. The majority of the messages were changed in some way including the removal of potentially triggering language. These messages were subsequently used in an ecological momentary intervention.
... Citation: Wittenborn AK, Hosseinichimeh N (2022) Exploring personalized psychotherapy for depression: A system dynamics approach. PLoS the effects of matching psychotherapy to patients' strengths versus their weaknesses, and findings showed that personalizing treatment to patients' strengths resulted in better depression outcomes than selecting treatment based on patients' deficits [10]. Building on this work, DeRubeis and colleagues [8] developed the Personalized Advantage Index (PAI) to predict whether psychotherapy or antidepressant medication would produce a better outcome for a given patient based on five pre-randomization variables; analyses of existing data revealed the PAI's potential for improving outcomes. ...
Depressive disorders are the leading contributor to medical disability, yet only 22% of depressed patients receive adequate treatment in a given year. Response to treatment varies widely among individuals with depression, and poor response to one treatment does not signal poor response to others. In fact, half of patients who do not recover from a first-line psychotherapy will recover from a second option. Attempts to personalize psychotherapy to patient characteristics have produced better outcomes than usual care, but research on personalized psychotherapy is still in its infancy. The present study explores a new method for personalizing psychotherapy for depression through simulation modeling. In this study, we developed a system dynamics simulation model of depression based on one of the major mechanisms of depression in the literature and investigated the trend of depressive symptoms under different conditions and treatments. Our simulation outputs show the importance of individualized services with appropriate timing, and reveal a new method for personalizing psychotherapy to heterogeneous individuals. Future research is needed to expand the model to include additional mechanisms of depression.
... Positive interventions and PPIs have been touted as an alternative or supplement to symptom-based techniques. The results of our metaanalysis are consistent with this assertion, as are other recent studies that have directly compared positive interventions with symptom-focused interventions (e.g., Cheavens et al., 2012;Craske et al., 2019;Dolev-Amit, 2020). These findings also raise the intriguing possibility that positive interventions could provide a useful adjunct to more problem-centered solutions. ...
Research on strengths-based positive interventions (SBPIs) has often supported their effectiveness, but these studies overwhelmingly focus on experiential outcomes such as affect and subjective well-being. Much less is known about their effectiveness for eliciting positive behavioral outcomes. The current article provides a lexicon to clarify distinctions between various types of positive interventions. This is followed by a meta-analysis of studies examining behavioral outcomes from SBPIs. Multiple databases were searched through October 2020. Out of 418 studies evaluating what could be considered SBPIs, only 48 analyses across 29 articles examined group differences in a behavioral outcome. Random-effects meta-analysis of post-test data revealed a small to medium, statistically significant effect, Hedges’ g= 0.32. Evidence was insufficient to suggest small-study or methodological bias. SBPIs seemed effective for eliciting behavioral change relative to control conditions consistent with prior meta-analyses. However, the available data are too limited to support SBPIs as an alternative to traditional approaches that focus on direct symptom reduction.
... Since RF may constitute a primary mechanism of change in TFP, a patient's pretreatment RF could be a prescriptive factor or moderator that predicts its clinical effects. In a compensation framework (Cheavens et al., 2012), we might expect TFP to be especially effective among patients with low RF, inasmuch as TFP helps patients resolve this deficit by encouraging mentalization through identifying and understanding the motivations, thoughts, and feelings underpinning different self-and other mental states. Alternatively, patients with higher RF could be expected to capitalize on their better RF and engage more productively in a treatment that focuses on the use and refinement of this capacity to make changes in personality organization and interpersonal functioning. ...
Background:
Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD). Transference-focused psychotherapy (TFP) has been demonstrated to improve RF compared to other common BPD treatments. If RF reflects a treatment mechanism for TFP, differences in pretreatment RF may also serve as a prescriptive factor for TFP's effects.
Method:
A total of 194 patients with BPD were randomized across two clinical trials to receive TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). A mixed-effects model was used to examine whether baseline RF interacted with treatment condition to predict slopes of change in the Brief Symptom Inventory, the shared symptom outcome between trials. Moderation of changes in RF was also examined.
Results:
Treatment interacted with baseline RF to predict BSI slopes (p = .011). In TFP/SPT, RF did not predict outcomes, β = -0.00, p = .973, while higher RF was associated with relatively better outcomes in DBT/eTAU, β = -0.54, p < .001. Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all.
Discussion:
Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... More specifically, the authors differentiated between compensation and capitalization models. While the first approach focuses on patients' deficits and symptoms and aims to compensate for these deficits, the second approach highlights patients' strengths and aims to build on these strengths in treatment (Cheavens et al., 2012;Cronbach & Snow, 1977). Based on a comprehensive review of the functionality of positive emotions, Fredrickson (2004) assumes, in her broaden-and-build theory, that not only do negative emotions narrow an individual's mindset, but positive emotions also broaden an individual's mindset. ...
Although cognitive behavioral therapy (CBT) is an effective treatment for generalized anxiety disorder (GAD), GAD often shows a chronic clinical course and common deterioration after treatment. Many trials have examined the efficacy of treatments in GAD, but little is known about intake predictors of long-term treatment outcomes. This study examined potential predictors of long-term treatment outcomes based on the individual’s symptom severity and strengths (behavioral, cognitive, interpersonal) at intake. Long-term outcomes were defined as worry at six-month follow-up (six-m FU) and worry decrease from intake and post-treatment to six-m FU. Data from 137 CBT outpatients with a GAD diagnosis from two randomized clinical trials were analyzed using three-level hierarchical linear modeling. Results revealed that worrying decreased up to the six-m FU. In single-predictor models, intake symptom severity and strength measures predicted worry at the six-m FU. In multi-predictor models, only behavioral strengths remained a significant predictor. Worry decrease from intake to the six-m FU was only predicted by behavioral strengths. These findings provide relevant information about intake predictors of long-term outcomes after CBT for GAD and underscore the potential relevance of assessing patients’ strengths for clinical practice.
... Capitalization describes the fact that pre-existing strengths of patients are reinforced and built on in therapy (73). In one study, tailoring treatment by focusing on patients' respective strengths rather than on their respective deficits led to better treatment outcomes in depressed patients (74). Since the intervention under study focuses, among other aspects, on building emotion regulation skills, it could be argued that emotion regulation skills were capitalized in participants with better pre-treatment emotion regulation skills. ...
Introduction
First evidence suggests that internet-based self-help interventions effectively reduce COVID-19 related psychological distress. However, it is yet unclear which participant characteristics are associated with better treatment outcomes. Therefore, we conducted secondary analyses on data from a randomized controlled trial investigating the efficacy of a 3-week internet-based self-help intervention for COVID-19 related psychological distress. In this exploratory analysis, we examined several predictors ranging from sociodemographic variables to psychological distress, resource-related, and treatment-related variables. This includes, for example, age, motivation, and emotion regulation skills. Treatment outcomes were defined as post-treatment depressive symptoms and post-treatment resilience.
Methods
In a total of 107 participants with at least mild depressive symptoms, possible predictor variables and treatment outcomes were assessed using self-report measures. For example, emotion regulation skills were assessed by the Self-report measure for the assessment of emotion regulation skills. In a first step, we performed a separate linear regression analysis for each potential predictor. In a second step, predictors meeting a significant threshold of p < 0.05 were entered in linear multiple regression models. Baseline scores of the respective outcome measure were controlled for.
Results
The mean age of the participants was 40.36 years (SD = 14.59, range = 18–81 years) with the majority being female (n = 87, 81.3%). Younger age predicted lower post-treatment depressive symptoms. Additionally, higher motivation to use the intervention and better pre-treatment emotion regulation skills predicted higher post-treatment resilience.
Conclusion
The current study provides preliminary evidence regarding the relationship between participant characteristics and treatment outcome in internet-based self-help interventions for COVID-19 related distress. Our results suggest that under the circumstances surrounding COVID-19 such interventions might be particularly beneficial for young adults regarding depressive symptoms. Moreover, focusing on participants' existing strengths might be a promising approach to promote resilience through internet-based self-help interventions. However, since this was an exploratory analysis in an uncontrolled setting, further studies are needed to draw firm conclusions about the relationship of participant characteristics and treatment outcome in internet-based self-help interventions for COVID-19 related psychological distress.
Psychotherapy integration aims to connect different psychotherapeutic theories and approaches while looking beyond the boundaries of individual procedures. Psychotherapists integrate various models and approaches in their daily practice to offer individually tailored therapies. The triple helix model of psychotherapy integration provides an overview of current integration efforts in psychotherapy, including theory formation, professional development and joint legal frameworks.
This chapter highlights the importance of integrating character strengths and peace psychology and science and practices therein. It discusses the natural connection and mutual benefit of these areas, exploring the previous lack of scientific and practical integration as potentially relating to a wide range of misconceptions about peace/peace psychology and about character strengths/positive psychology. The misconceptions are detailed alongside corrective realities. A model for integrating character strengths and peace psychology is explained and offered as a framework for this book, Peace Psychology and Character Strengths. The model emphasizes “levels” of peace, including inner, relational, intragroup, intergroup, community, international, and ecological peace; “types” of peace as positive peace (amplifying harmony, balance, calmness) and negative peace (reducing conflict, aggression, violence) occurring at any level of peace; and character strengths in the form of character strengths’s concepts, specific character strengths, and character strengths’s dynamics across levels and types of peace. The chapter then examines the potential practicality of integrating peace and character strengths by sharing a study indicating feasibility and conducting two new studies, one on motivation to take action (N = 16,126) and the other on commitment to an action relating character strengths to peace within 1 week (N = 13,932). These studies show initial support for feasibility, motivation (both importance and confidence components), and commitment to action. This is followed by a summary of themes and insights from a 5-week pilot group integrating character strengths and peace, with emphasis on inner peace and relational peace, and to a lesser degree, group peace. This group revealed further support and benefit for the integration as well as the usefulness of weaving in character strength concepts, specific strengths, and character strength dynamics. Finally, science-based strategies for inner peace and relational peace are outlined for all 24-character strengths; these extrapolations serve as examples for further research.
Objective:
Self-guided digital mental health interventions (DMHIs) teaching empirically supported skills (e.g. behavioral activation) have demonstrated efficacy for improving youth mental health, but we lack evidence for the complex skill of cognitive restructuring (CR).
Method:
We conducted the first-ever RCT testing a CR DMHI ("Project Think") against an active control (supportive therapy; "Project Share") in collaboration with public schools. Pre-registered outcomes were DMHI acceptability and helpfulness post-intervention, as well as internalizing symptoms and CR skills use from baseline to seven-month follow-up, in the full sample and the subsample with elevated symptoms.
Results:
Participants (N = 597; MAge = 11.99; 48% female; 68% White) rated both programs highly on acceptability and helpfulness. Both conditions were associated with significant internalizing symptom reductions across time in both samples, with no significant condition differences. CR skills use declined significantly across time for Project Share youths but held steady across time for Project Think youths in both samples; this pattern produced a significant condition difference favoring Project Think within the elevated sample at seven-month follow-up.
Conclusion:
Internalizing symptoms declined comparably for Think and Share participants. Consequently, future research should examine whether encouraging youths to share their feelings produces symptom improvements, and whether a single-session, self-guided CR DMHI produces beneficial effects relative to more inert control conditions. Further, the decline in CR skills use for Project Share youths versus sustained CR use by Project Think youths raises questions about the natural time course of youths' CR use and the impact of these DMHIs on that course. ClinicalTrials.gov Registration: NCT04806321.
Precision medicine methods (machine learning; ML) can identify which clients with generalized anxiety disorder (GAD) benefit from mindfulness ecological momentary intervention (MEMI) vs. self-monitoring app (SM). We used randomized controlled trial data of MEMI vs. SM for GAD (N = 110) and tested three ML models to predict one-month follow-up reliable improvement in GAD severity, perseverative cognitions (PC), trait mindfulness (TM), and executive function (EF). Eleven baseline predictors were tested regarding differential reliable change from MEMI vs. SM (age, sex, race, EF errors, inhibitory dyscontrol, set-shifting deficits, verbal fluency, working memory, GAD severity, TM, PC). The final top five prescriptive predictor models of all outcomes performed well (AUC = 0.752–0.886). The following variables predicted better outcome from MEMI vs. SM: Higher GAD severity predicted more GAD improvement but less EF improvement. Elevated PC, inhibitory dyscontrol, and verbal dysfluency predicted better improvement in most outcomes. Greater set-shifting and TM predicted stronger improvements in GAD symptoms and TM. Older age predicted more alleviation of GAD and PC symptoms. Women exhibited more enhancements in trait mindfulness and EF than men. Caucasians benefitted more than non-Caucasians. PC, TM, EF, and sociodemographic data could help predictive models optimize intervention selection for GAD.
This chapter lays the foundation for strengths-based, positive psychology, and well-being approaches and outlines the context of understanding and helping people with disabilities. The argument for the importance of character strengths is made through a conceptual and scientific lens. Research studies are reviewed that show a focus on amplifying strengths reveals greater benefits than remediating deficits in many situations. The different kinds of strengths—talents, skills, interests, resources, character strengths—are differentiating and mapped out in practical ways. A functional approach to strengths for disability is discussed. The concepts, research, and practices discussed in this chapter offer ramifications for the chapters that follow.KeywordsStrengths-based approachDisabilityPositive psychologyWell-beingStrengths vs deficitsStigmaTalentsSkillsInterestsResources
Coping intelligently with global public mental health threats means resolving challenges at an individual and societal level by efficiently utilizing professional expertise and critical thinking. Philosophical underpinning of coping with pandemic and infodemic stress approach facilitates clarity regarding the course of public mental health actions to navigate immediate and forthcoming complex situations, such as those arising from the global crisis caused by the virus SARS-CoV-2 and coronavirus disease (COVID-19). To cope efficiently with global challenges, professional public mental health communities need to promote a culture of awareness and preparedness for pandemic, as well as infodemic including global spread of distorted news, false information, and statistical simulations based on biased expert opinions. Indeed, evidence suggests that during a pandemic, the general public, politicians, medical experts, and governments are vulnerable to deepfakes, such as deliberate misinformation, and public mental health risks involving fear, panic, xenophobic attitudes (e.g., scapegoating), and racial biases.
Further, societal responses demonstrate that damage caused by the widespread infodemic exceeds the pandemic’s biomedical impact. For example, mass fear and anxiety instilled by confusion and distrust in the ability to cope with a crisis on an individual and group level results in negative impacts to mental health. The emergency situation caused by pandemic will pass, but the psychosocial consequences will remain long-term, and their impact on human lives will depend on our efforts to build personal and societal adequate expertise based on coping intelligence and resilience, in addressing unforeseen challenges.
The aim of this collection of research papers was to provide a unique opportunity for an interdisciplinary article collection that welcomes contributions from public mental health professionals, psychologists, sociologists, epidemiologists, science methodologists, philosophers, AI researchers, and digital mass media experts. The goal is to share conceptual insights and practical guidelines to develop successful mental health coping strategies during times of uncertainty and global challenges. Specifically, this Research Topic will focus on successful coping strategies in the area of public mental health implemented at any level - individual, national, regional, and global.
Objective
The available literature points to the potential therapeutic benefits of alliance strengthening during treatment. Both supportive and expressive techniques have been suggested to be associated with strengthening of the alliance. The present study investigates whether patients may show different effects of supportive vs. expressive techniques in improving alliance as a function of their pretreatment insight levels.
Method
Fifty-five patients were randomly assigned to either supportive treatment (ST) or supportive-expressive treatment (SET), as part of a larger randomized controlled trial. Clinical interviews were administered at pretreatment to evaluate the patients’ level of insight. The working alliance was measured after each of the 16 sessions. A multilevel model, including a 3-way interaction of pretreatment insight by treatment condition (ST vs. SET) by time, was used to predict alliance strengthening.
Results
The findings suggest that, for individuals receiving ST, those with higher levels of insight show greater alliance strengthening. For individuals receiving SET, those with lower levels of insight show greater alliance strengthening.
Conclusion
The current study suggests that one size may not fit all and, whereas some individuals may benefit more from ST to achieve alliance strengthening, others may benefit more from SET.
Objective:
In psychotherapy, strength-based methods (SBM) represent efforts to build on patients' strengths while addressing the deficits and challenges that led them to come to therapy. SBM are incorporated to some extent in all major psychotherapy approaches, but data on their unique contribution to psychotherapy efficacy is scarce.
Methods:
First, we conducted a systematic review and narrative synthesis of eight process-outcome psychotherapy studies that investigated in-session SBM and their relation to immediate outcomes. Second, we conducted a systematic review and multilevel comparative meta-analysis contrasting strength-based bona fide psychotherapy vs. other bona fide psychotherapy at post-treatment (57 effect sizes nested in 9 trials).
Results:
Despite their methodological variability, the pattern of results in the process-outcome studies was generally positive, such that SBM were linked with more favorable immediate, session-level patient outcomes. The comparative meta-analysis found an overall weighted average effect size of g = 0.17 (95% CIs [0.03, 0.31], p < .01) indicating a small but significant effect in favor of strength-based bona fide psychotherapies. There was non-significant heterogeneity among the effect sizes (Q(56) = 69.1, p = .11; I2 = 19%, CI [16%, 22%]).
Conclusion:
Our findings suggest that SBMs may not be a trivial by-product of treatment progress and may provide a unique contribution to psychotherapy outcomes. Thus, we recommend integration of SBM to clinical training and practice across treatment models.
Background
Research on outcome predictors in the field of transcultural treatment for refugees and asylum seekers (RAS) is scarce. We aimed to evaluate predictors of outcome of a group intervention (Empowerment) for RAS with affective disorders which were incorporated at level three of the stratified stepped-care model within the Mental Health in Refugees and Asylum Seekers (MEHIRA) project.
Methods
A predictor analysis was performed at level three of the MEHIRA project, where 149 refugees with moderate depressive symptoms were treated either with Empowerment or Treatment-as-usual (TAU). Outcome measures were depression severity as assessed by patient-rated Patient Health Questionnaire 9 (PHQ-9) and clinician-rated Montgomery Asberg Depression Rating Scale (MADRS). Regression models with change scores (T1–T0) of PHQ-9 and MADRS as dependent variables were fit. Predictor selection was a mixed-method approach combining testing of literature-based hypotheses and explorative hypothesis-generating analyses of multiple baseline variables.
Results
Intention-to-treat (ITT) analyses revealed significant linear relationships between change in PHQ-9 and baseline depression severity (β = −0.35, t = −3.27, p = .002) and perceived self-efficacy (β = −0.24, t = −2.26, p = .027) in the treatment (verum) condition. MADRS change scores were predicted by baseline depression severity (β = −0.71, t = −8.65, p < .001) in the treatment (verum) condition.
Limitations
Due to small cell numbers, single predictors could not be evaluated reliably.
Conclusions
Severity of depression and self-efficacy at baseline were predictors of symptom improvement at level three (Empowerment) of the MEHIRA project. Comorbidity and trauma indicators did not predict outcomes in the treatment (verum) condition, pointing towards broad applicability of the Empowerment intervention in refugee populations.
Objective
Meta-analytic evidence showed robust associations between the alliance in psychotherapeutic dyads and treatment outcomes. Recent studies have indicated that facets of positive mental health are additionally relevant predictors of both the alliance and success of psychotherapy. However, the impact of patients’ pre-therapy strengths on the alliance at the beginning and during treatment has been scarcely examined.
Method
428 patients (62.4% female, Mage = 40.79), treated by 41 therapists, underwent cognitive behavioral therapy in a German outpatient training and research center. Alliance from patients’ perspectives was assessed at the beginning and during treatment. Data were analyzed with multilevel growth curve modeling.
Results
Alliance increased during psychotherapy, with a quadratic trajectory best representing this trend on average, p < .001. Pre-therapy strengths were positively related to alliance intercept, b = 0.0537, p < .001. No interaction was found between the included time variables and pre-therapy strengths in the prediction of the alliance slope.
Conclusion
Positive mental health facets should be considered in psychotherapy research and practice. Future studies may focus on the parallel development of patients’ strengths with other process factors in treatment.
In this chapter, we provide an overview of what has been described as the second wave of behavior therapy: cognitive therapy or cognitive behavioral therapy (CBT). These therapies are well-supported and increasingly widely practiced. We provide an overview of the origins and defining features of these approaches. Following early work establishing cognitive behavioral therapies, cognitive behavioral models of many specific disorders have been developed and tested. Key to the success of cognitive behavioral treatments has been the commitment to empirical evaluation. Randomized clinical trials have established cognitive behavioral treatments as among the best supported of all psychosocial interventions.
The alliance has been a leading player in the long-running debate on whether therapeutic change is driven by factors common across distinct treatments or by treatment-specific factors. The present study disentangled between-patients differences in alliance strength from within-patient changes to investigate whether two treatments with identical goals but based on different roles of alliance differ in the within-patient effect of alliance on outcome. Both treatments are aimed at improving the patients' interpersonal abilities, but in the supportive treatment (ST) the alliance is the main specific factor, whereas in the supportive-expressive treatment (SET) it is conceptualized as a common factor. One hundred patients were randomized to receive either ST or SET. Treatment outcome and alliance were assessed weekly. Treatment condition significantly moderated the effect of within-patient changes in the alliance (relative to its mean) on subsequent treatment outcome, so that any increases in state-like alliance predicted lower levels of subsequent depressive symptoms in ST than in SET. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
Anhedonia-the loss of pleasure or lack of reactivity to pleasurable stimuli-remains a formidable treatment challenge across neuropsychiatric disorders. In major depressive disorder, anhedonia has been linked to poor disease course, worse response to psychological, pharmacological, and neurostimulation treatments, and increased suicide risk. Moreover, although some neural abnormalities linked to anhedonia normalize after successful treatment, several persist-for example, blunted activation of the ventral striatum to reward-related cues and reduced functional connectivity involving the ventral striatum. Critically, some of these abnormalities have also been identified in unaffected, never-depressed children of parents with major depressive disorder and have been found to prospectively predict the first onset of major depression. Thus, neural abnormalities linked to anhedonia may be promising targets for prevention. Despite increased appreciation of the clinical importance of anhedonia and its underlying neural mechanisms, important gaps remain. In this overview, the author first summarizes the extant knowledge about the pathophysiology of anhedonia, which may provide a road map toward novel treatment and prevention strategies, and then highlights several priorities to facilitate clinically meaningful breakthroughs. These include a need for 1) appropriately controlled clinical trials, especially those embracing an experimental therapeutics approach to probe target engagement; 2) novel preclinical models relevant to anhedonia, with stronger translational value; and 3) clinical scales that incorporate neuroscientific advances in our understanding of anhedonia. The author concludes by highlighting important future directions, emphasizing the need for an integrated, collaborative, cross-species, and multilevel approach to tackling anhedonic phenotypes.
Response to specific depression treatments varies widely among individuals. Understanding and predicting that variation could have great benefits for people living with depression.
The authors describe a conceptual model for identifying and evaluating evidence relevant to personalizing treatment for depression. They review evidence related to three specific treatment decisions: choice between antidepressant medication and psychotherapy, selection of a specific antidepressant medication, and selection of a specific psychotherapy. They then discuss potential explanations for negative findings as well as implications for research and clinical practice.
Many previous studies have examined general predictors of outcome, but few have examined true moderators (predictors of differential response to alternative treatments). The limited evidence indicates that some specific clinical characteristics may inform the choice between antidepressant medication and psychotherapy and the choice of specific antidepressant medication. Research to date does not identify any biologic or genetic predictors of sufficient clinical utility to inform the choice between medication and psychotherapy, the selection of specific medication, or the selection of a specific psychotherapy.
While individuals vary widely in response to specific depression treatments, the variability remains largely unpredictable. Future research should focus on identifying true moderator effects and should consider how response to treatments varies across episodes. At this time, our inability to match patients with treatments implies that systematic follow-up assessment and adjustment of treatment are more important than initial treatment selection.
The authors investigated patient characteristics predictive of treatment response in the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program.
Two hundred thirty-nine outpatients with major depressive disorder according to the Research Diagnostic Criteria entered a 16-week multicenter clinical trial and were randomly assigned to interpersonal psychotherapy, cognitive-behavior therapy, imipramine with clinical management, or placebo with clinical management. Pretreatment sociodemographic features, diagnosis, course of illness, function, personality, and symptoms were studied to identify patient predictors of depression severity (measured with the Hamilton Rating Scale for Depression) and complete response (measured with the Hamilton scale and the Beck Depression Inventory).
One hundred sixty-two patients completed the entire 16-week trial. Six patient characteristics, in addition to depression severity previously reported, predicted outcome across all treatments: social dysfunction, cognitive dysfunction, expectation of improvement, endogenous depression, double depression, and duration of current episode. Significant patient predictors of differential treatment outcome were identified. 1) Low social dysfunction predicted superior response to interpersonal psychotherapy. 2) Low cognitive dysfunction predicted superior response to cognitive-behavior therapy and to imipramine. 3) High work dysfunction predicted superior response to imipramine. 4) High depression severity and impairment of function predicted superior response to imipramine and to interpersonal psychotherapy.
The results demonstrate the relevance of patient characteristics, including social, cognitive, and work function, for prediction of the outcome of major depressive disorder. They provide indirect evidence of treatment specificity by identifying characteristics responsive to different modalities, which may be of value in the selection of patients for alternative treatments.
A TEST BATTERY ASSESSING SPECIFIC AND GENERAL TREATMENT EFFECTS WAS READMINISTERED TO SS PREVIOUSLY ASSESSED BEFORE TREATMENT, AFTER TREATMENT, AND AT A 6-WK FOLLOW-UP FROM GROUPS UNDERGOING INDIVIDUAL PROGRAMS OF (1) MODIFIED SYSTEMATIC DESENSITIZATION, (2) INSIGHT-ORIENTED PSYCHOTHERAPY, (3) ATTENTION-PLACEBO TREATMENT, AND (4) NO TREATMENT. HIGHER RETURN RATES WERE OBTAINED THAN IN ANY PREVIOUS LONG-TERM FOLLOW-UP, REVEALING MAINTAINANCE OF IMPROVEMENT FOUND EARLIER FOR INTERPERSONAL PERFORMANCE ANXIETY. SYSTEMATIC DESENSITIZATION RESULTED IN THE GREATEST SIGNIFICANT IMPROVEMENT (85%), FOLLOWED BY INSIGHT-ORIENTED PSYCHOTHERAPY AND ATTENTION PLACEBO (50% EACH), AND UNTREATED CONTROLS (22%). CHANGES WERE RELIABLE, PREDICTABLE, AND SHOWED EVIDENCE OF FURTHER GENERALIZATION. NO EVIDENCE OF RELAPSE OR SYMPTOM SUBSTITUTION WAS OBTAINED, ALTHOUGH THEY WERE SPECIFICALLY SOUGHT. METHODOLOGICAL PROBLEMS OF FOLLOW-UP STUDIES ARE ALSO DISCUSSED. (36 REF.)
Efforts to increase the practice of evidence-based psychotherapy in the United States have led to the formation of task forces to define, identify, and disseminate information about empirically supported psychological interventions. The work of several such task forces and other groups reviewing empirically supported treatments (ESTs) in the United States, United Kingdom, and elsewhere is summarized here, along with the lists of treatments that have been identified as ESTs. Also reviewed is the controversy surrounding EST identification and dissemination, including concerns abou research methodology, external validity, and utility of EST research, as well as the reliability and transparency of the EST review process.
This study assessed the efficacy of 1) matching patients to treatments and 2) adding additional family therapy or cognitive therapy in a group of recently discharged patients with major depression.
Patients with major depression were recruited during a psychiatric hospitalization. After discharge, they were randomly assigned to one of four treatment conditions that were either "matched" or "mismatched" to their pattern of cognitive distortion and family impairment. The four treatment conditions were 1) pharmacotherapy alone; 2) combined pharmacotherapy and cognitive therapy; 3) combined pharmacotherapy and family therapy; and 4) combined pharmacotherapy, cognitive therapy, and family therapy. Randomly assigned treatment continued for 24 weeks on an outpatient basis.
Among patients with at least moderate depressive symptoms at hospital discharge, low rates of remission (16%) and improvement (29%) were obtained. Matched treatment led to a significantly greater proportion of patients who improved and greater reductions over time in interviewer-rated depressive symptoms than mismatched treatment. However, matched treatment did not produce greater change in self-reported depression or interviewer-rated suicidal ideation. Treatment that included a family therapy component also led to a greater proportion of patients who improved and to significant reductions in interviewer-rated depression and suicidal ideation than treatment without family therapy.
These results suggest that 1) current treatments are not very efficacious in the aftercare of hospitalized depressed patients, 2) treatment matching moderately improves outcome for patients who are symptomatic at hospital discharge, and 3) inclusion of family therapy improves the outcome of posthospital care for depressed patients.
Self-system therapy (SST) is a new therapy based on regulatory focus theory (E. T. Higgins, 1997) for depressed individuals unable to pursue promotion goals effectively. The authors conducted a randomized trial comparing SST with cognitive therapy (CT) in a sample of 45 patients with a range of depressive symptoms to test 2 hypotheses: that SST would be more efficacious for depressed individuals characterized by inadequate socialization toward pursuing promotion goals and that SST would lead to greater reduction in dysphoric responses to priming of promotion goals. There was no overall difference in efficacy between treatments, but patients whose socialization history lacked an emphasis on promotion goals showed significantly greater improvement with SST. In addition, SST patients showed a greater reduction in dysphoric responses to promotion goal priming than did CT patients. The results illustrate the value of a theory-based translational approach to treatment design and selection.
• The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders. It consists of a semistructured interview, an instruction booklet, a coding sheet, and a set of training materials. An interviewer uses the LIFE to collect detailed psychosocial, psychopathologic, and treatment information for a six-month follow-up interval. The weekly psychopathology measures ("psychiatric status ratings") are ordinal symptom-based scales with categories defined to match the levels of symptoms used in the Research Diagnostic Criteria. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed in patients or developing during the follow-up. Any DSM-III or Research Diagnostic Criteria disorder can be rated with the LIFE, and any length or number of follow-up intervals can be accommodated. The psychosocial and treatment information is recorded so that these data can be linked temporally to the psychiatric status ratings.
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THE MOST PRACTICAL, UP-TO-DATE GUIDE TO MODELLING AND ANALYZING TIME-TO-EVENT DATANOW IN A VALUABLE NEW EDITION Since publication of the first edition nearly a decade ago, analyses using time-to-event methods have increase considerably in all areas of scientific inquiry mainly as a result of model-building methods available in modern statistical software packages. However, there has been minimal coverage in the available literature to9 guide researchers, practitioners, and students who wish to apply these methods to health-related areas of study. Applied Survival Analysis, Second Edition provides a comprehensive and up-to-date introduction to regression modeling for time-to-event data in medical, epidemiological, biostatistical, and other health-related research. This book places a unique emphasis on the practical and contemporary applications of regression modeling rather than the mathematical theory. It offers a clear and accessible presentation of modern modeling techniques supplemented with real-world examples and case studies. Key topics covered include: variable selection, identification of the scale of continuous covariates, the role of interactions in the model, assessment of fit and model assumptions, regression diagnostics, recurrent event models, frailty models, additive models, competing risk models, and missing data. Features of the Second Edition include: Expanded coverage of interactions and the covariate-adjusted survival functions The use of the Worchester Heart Attack Study as the main modeling data set for illustrating discussed concepts and techniques New discussion of variable selection with multivariable fractional polynomials Further exploration of time-varying covariates, complex with examples Additional treatment of the exponential, Weibull, and log-logistic parametric regression models Increased emphasis on interpreting and using results as well as utilizing multiple imputation methods to analyze data with missing values New examples and exercises at the end of each chapter Analyses throughout the text are performed using Stata Version 9, and an accompanying FTP site contains the data sets used in the book. Applied Survival Analysis, Second Edition is an ideal book for graduate-level courses in biostatistics, statistics, and epidemiologic methods. It also serves as a valuable reference for practitioners and researchers in any health-related field or for professionals in insurance and government.
The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Behavioral activation is a positive approach to treating depression. Working within this framework the therapist helps clients to see depression not as something inside of them but as a natural consequence of the way they cope with the shifting contexts of daily life. There is no search for mental illness, skill deficits, or distortions in thinking. Rather, the therapist coaches the client to engage in activities that will lead to a more rewarding life. This book is arranged in 3 parts. Part I reviews theories of depression and various treatments for depression, particularly pharmacological treatments, cognitive therapy, and behavioral therapy. Part II describes the behavioral activation treatment approach and provides ample case transcript material. Part III looks at problems that can arise in therapy and at future opportunities for the use of behavioral activation. Combining practical, theoretical, and empirical discussions, this book will be of value to a wide range of clinicians, students, and anyone interested in the treatment of depression. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The Longitudinal Interval Follow-up Evaluation (LIFE) is an integrated system for assessing the longitudinal course of psychiatric disorders. It consists of a semistructured interview, an Instruction booklet, a coding sheet, and a set of training materials. An interviewer uses the LIFE to collect detailed psychosocial, psychopathologic, and treatment information for a six-month follow-up interval. The weekly psychopathology measures ("psychiatric status ratings") are ordinal symptom-based scales with categories defined to match the levels of symptoms used in the Research Diagnostic Criteria. The ratings provide a separate, concurrent record of the course of each disorder initially diagnosed in patients or developing during the follow-up. Any DSM-III or Research Diagnostic Criteria disorder can be rated with the LIFE, and any length or number of follow-up intervals can be accommodated. The psychosocial and treatment information is recorded so that these data can be linked temporally to the psychiatric status ratings.
While the Hamilton Rating Scale for Depression (HRSD) has been the standard instrument for the assessment of the severity of depression for many years, this scale has a number of limitations. We developed the Modified Hamilton Rating Scale for Depression (MHRSD) to overcome some of these limitations and to enable paraprofessional research assistants to make reliable and valid assessments of depressive symptoms. The present study investigates the reliability and validity of the MHRSD. Interrater reliability among paraprofessional research assistants was excellent. The relationship between the MHRSD and expert clinician ratings on the MHRSD and the original HRSD was also high. Thus, the MHRSD appears to be a useful addition to the clinical researcher's assessment battery.
Consider a study in which 2 groups are followed over time to assess group differences in the average rate of change, rate of acceleration, or higher degree polynomial effect. In designing such a study, one must decide on the duration of the study, frequency of observation, and number of participants. The authors consider how these choices affect statistical power and show that power depends on a standardized effect size, the sample size, and a person-specific reliability coefficient. This reliability, in turn, depends on study duration and frequency. These relations enable researchers to weigh alternative designs with respect to feasibility and power. The authors illustrate the approach using data from published studies of antisocial thinking during adolescence and vocabulary growth during infancy.
Previous research has supported the immediate activation of patient's strengths (resource activation) as an important mechanism of change in psychotherapy. We designed a brief (10 min) priming procedure in which therapists' attention was focused on the patients' individual strengths before each therapy session (resource priming). In a preliminary study, the priming procedure was carried out before each of the first five sessions (N=20). Preliminary results indicated that this brief preparatory intervention boosted resource activation as perceived by independent observers, fostered attachment and mastery experiences by the patient, and improved therapy outcome at Session 20. Improvement was assessed in comparison to a pairwise matched, nonrandomized control group of patients treated previously with the same treatment protocol at the same clinic.
Cognitive therapy of depression Beck depression inventory manual
- A T Beck
- A J Rush
- B F Shaw
- G Emery
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press. Beck, A. T., Steer, R. A., & Brown, B. K. (1996). Beck depression inventory manual (2nd ed.). San Antonio, TX: Psychological Corporation.
Adapting cognitive therapy for depression: Managing complexity and comorbidity
- M A Whisman
Whisman, M. A. (2008). Adapting cognitive therapy for depression: Managing complexity and comorbidity. New York: Guilford Press. J.S. Cheavens et al. / Behaviour Research and Therapy 50 (2012) 699e706
- S M Sotsky
- D R Glass
- M T Shea
- P A Pilkonis
- J F Collins
- Moyer
Sotsky, S. M., Glass, D. R., Shea, M. T., Pilkonis, P. A., Collins, J. F., & Moyer, J. (1991).