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Cognitive Behavioral Therapy - Science topic

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I am looking for researchers who have studied the impact of remote, eHealth, mobile or internet treatments for binge eating disorder (BED). If you have conducted such studies (or know a team that has), have the results been published and/or is there anywhere this data can be accessed?
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Hi Elnaz
Here are some recent references on BED and Internet or smartphone treatment:
  • Hildebrandt, T., Michaeledes, A., Mayhew, M., Greif, R., Sysko, R., Toro-Ramos, T., & DeBar, L. (2020). Randomized controlled trial comparing health coach-delivered smartphone-guided self-help with standard care for adults with binge eating. American Journal of Psychiatry, 177(2), 134-142.
  • Jensen, E. S., Linnet, J., Holmberg, T. T., Tarp, K., Nielsen, J. H., & Lichtenstein, M. B. (2020). Effectiveness of internet‐based guided self‐help for binge‐eating disorder and characteristics of completers versus noncompleters. International Journal of Eating Disorders, 53(12), 2026-2031.
  • Yim, S. H., Bailey, E., Gordon, G., Grant, N., Musiat, P., & Schmidt, U. (2020). Exploring Participants’ Experiences of a Web-Based Program for Bulimia and Binge Eating Disorder: Qualitative Study. Journal of medical Internet research, 22(9), e17880.
Keith
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I am trying to find evidence that CBT is useful for improving neuropsychiatric symptoms (such as depression, anxiety, agitation, mood, etc) in patients suffering from mild cognitive impairment or mild Alzheimer's Disease. I would be grateful if you could share individual studies or a review/meta-analysis meeting this criteria. Thank you.
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There are so many. Some, for example: JJG Galve "[PDF] Review of scientific evidence of cognitive-behavioral therapy" - Naturopathic Medicine, 2009 - dialnet.unirioja.es; Fernández-Álvarez, Héctor and Fernández-Álvarez, Javier. (2017) Integrative cognitive behavioral therapy. Journal of Psychopathology and Clinical Psychology 22 (2), 157-169; Bragança, Miguel; Palha, A .: Actas Espanolas de Psiquiatria. November / December 2011, vol. 39 Edition 6, p374-383 "Neurocognitive Disorders Associated with HIV Infection and Cognitive Behavioral Therapy"; "Effect of a cognitive-behavioral intervention on emotional variables in older adults", Daniela Contreras, Mónica Moreno, Pablo Esteban Livacic Rojas, Pablo E. Vera Villarroel, Patricia Araya, Natalia Martínez. Latin American Journal of Psychology, ISSN 0120-0534, Vol. 38, Nº. 1, 2006, pp. 45-58.
They are in Spanish and I think they are quite good from a scientific point of view.
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Does anyone know of any work dealing with fear of relaxation? I have seen this come up with patients and have found exposure principles a helpful addition to treatment. I've been searching around and haven't come up with much of anything. Thanks!
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Relaxation sensitivity indexes the fear of relaxation-related events. The purpose of this study was to develop and provide initial validation of a self-report measure of relaxation sensitivity, the Relaxation Sensitivity Index (RSI). Three independent samples of undergraduate students (n = 300 unselected, n = 349 nonclinical, and n = 197 with elevated anxiety/depression symptoms) completed self-report measures to examine the factor structure, reliability, and validity of the RSI. Results of exploratory and confirmatory factor analyses supported a three-factor structure (correlated physical, cognitive, and social concerns). The RSI demonstrated good internal consistency and construct validity as evidenced by expected correlations with measures of anxiety and depression symptoms. The RSI showed good predictive validity in terms of a history of fearful responding to relaxation. RSI scores were significantly higher in the symptomatic compared with nonclinical sample. Results suggest the RSI is a valid and reliable measure that may be useful in clinical and research settings.
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The efficacy of CBT in treating Anorexia Nervosa is inconclusive. Through reading I have not encountered many papers that discuss CBT's efficacy based on individual components - e.g. Cognitive restructuring and distortions.
Are there any interesting papers out there like this?
Thank you
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This paper is not new but may be of interest. Family Based Therapy is generally the treatment of choice for adolescents with anorexia nervosa, but CBT is recommended as an individual treatment for all individuals with anorexia by most published guidelines.
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The efficacy of CBT in treating Anorexia Nervosa is inconclusive. Through reading I have not encountered many papers that discuss CBT's efficacy based on the individual components - e.g. Cognitive restructuring.
I'm interested in what components of CBT are most effective and which are not -
Are there any interesting / useful papers out there?
Thank you
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All guidelines I am familiar with recommend Family Based Therapy for adolescents with anorexia nervosa. However, many guidelines in fact recommended cognitive-behavioral therapy as an individual treatment approach at some level because it intervenes at the symptom level and centers on the modification of dysfunctional behaviors and cognitions that maintain the disorder. It was recommended as a first-line psychotherapy for AN by guidelines in the Netherlands and the United Kingdom. I'm attaching a few papers that may be of interest.
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Looking at Anorexia Nervosa - the evidence base for CBT's effectiveness is inconclusive. Though, I was thinking before about the link between Anorexia and emotions (not being able to express / experiencing negative emotions - and partly "using" food restriction as a way to control these) - let's say a strong therapeutic bond is formed, and an individual feels comfortable discussing extraneous feelings / thoughts - could this help with the need for food as a control mechanism and aid recovery in some way..
Not sure there is much evidence on this though.
Any thoughts?
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Yes, there isn't conclusive evidence to support the efficacy of CBT for Anorexia Nervosa. In general, CBT, family-based treatment, and interpersonal therapy for eating disorders.
These articles may interest you:
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I just came across a really interesting point of view in a clinical manual by a leading author in clinical treatment in Spain, Miguel Ángel Vallejo. He claims, based on a study by Rude and Rehm (1991)*, that psychotherapy is most effective when it boosts already-existing capacities and skills, rather than when it focuses on ameliorating deficits. That seems to run counter to much of what I have seen before in psychotherapy; does this idea match your clinical experience, or do you have any additional bibliography that might support this claim Thanks a lot!
*The citation to this article is given as "Rude, S. S., & Rehm, L. P. (1990). Cognitive and behavioral predictors of response to treatments for depression. Clinical Psychology Review, 11, 493–514"; however, all I can find online is this other article, with a different name, although (apparently) similar content: https://psycnet.apa.org/record/1992-06180-001
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"In psychotherapy, is it better to boost current skills or mitigate deficits?"
I just discovered this important question. If we go beyond the question of depression alone and ask a more general question about the psychotherapies - from psychoanalytic to behavioral and cognitive therapies to relational therapies, we can discern more general patterns of what happens in therapy.
Using information theory and systemic therapy as a model (but this applies to all therapies), we do three simple things in therapy (Di Nicola, 1997):
  • Enhance uncertainty (show that their current repertoire is limited or that their way of framing things can be improved)
  • Introduce novelty (suggest other ways of examining the problem from new perspectives)
  • Encourage diversity (stimulate new ways of thinking and being, beyond their current repertoire in order to be more adaptive to current and future challenges)
So, my specific answer to this question - "In psychotherapy, is it better to boost current skills or mitigate deficits?" - is that another option is missing which is to introduce novelty, new ways of looking at things and new ways of living. This means in the frame of this question, new skills, as opposed to boosting skills already in place or mitigating lack. Let me be clear: offering to model or teach new skills is not necessarily addressing a lack. It may simply be the case that the person never confronted a given situation and needs to add to their repertoire of skills.
Vincenzo Di Nicola, MPhil, MD, PhD
Université de Montréal &
The George Washington University
Reference: Di Nicola, V. (1997). A Stranger in the Family: Culture, Families, and Therapy. New York & London: WW Norton & Co.
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I know there is (somewhat) widespread agreement that relaxation techniques can be used as a form of avoidance of exposure in panic disorder, and hence breathing techniques and progressive muscle relaxation are discouraged so that the client feels the full physiological activation and becomes aware that the symptoms that he/she experiences are not actually dangerous or life-threatening in any way.
However, I was wondering whether this would apply as well to exposures in other forms of anxiety, say, specific phobia or social phobia. In those instances, it seems to me that the exposure to the phobic stimulus is not prevented by the relaxation/breathing techniques, and so these techniques would be merely an aid to facilitate the exposure. The client would not habituate to the physiological activation (which would be dampened by the relaxation techniques), but he/she could still dispel his/her irrational beliefs about coming into contact with the feared object.
Any science to back this up?
Cheers!
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Marc Josep Garcia Hervás that sounds like an interesting idea! And I suppose it would depend on the ultimate aim- to eliminate distress or manage more effectively?
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It is currently believed that TAF bias commonly found pronounced in OCD individuals requires specific treatment options for relieving distress. However, TAF is generally considered as one of the various prevalent irrational biases that come under umbrella construct of "over-importance of thoughts". In Cognitive Therapy, TAF is addressed like any other cognitive distortions and same techniques are applied to overcome this maladaptive style of thinking like are done with other distortions. TAF becomes prominent in many sub-classes of OCD individuals, specifically those with obsessions in absence of compulsions (immoral impulses or urges). Are you aware of any specific techniques and methods to treat TAF?
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You might also want to read this paper on cognitive bias modification for TAF biases:
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I have a feeling that the specificity of exposure should be more or less irrelevant in behavioral therapy of agoraphobia secondary to panic disorder, since the fear is of being unable to escape or receive help regardless of the specific surroundings, as opposed to what one might observe in situational specific phobia. Therefore, it shouldn't matter whether one is stuck on a plane or in an elevator, for instance, and exposure should work in both situations. However, I can't find any research to sustain this claim. Could anybody point me in the right direction? Thank you very much!
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"since the fear is of being unable to escape or receive help regardless of the specific surroundings, as opposed to what one might observe in situational specific phobia."
I think it is precisely related to specific surroundings. Erasmus Darwin noted it in travel across a snow-filled landscape where visual reference points were absent. The problem is one of body and space instability due to fluctuating vestibular dysfunction in the inner ear where compensatory visual fixation is absent or ambiguous.
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Hi guys,
I'm looking for a CBT manual that teaches you how to apply CBT to different disorders; that is, the book that I'm looking for would have a break-down of all disorders to which CBT can be applied, and within each section you'd have specific information of how to tailor the protocol to that specific disorder.
Stefan Hofmann has something like this in his "An Introduction to Modern CBT", where he touches upon panic disorder, agoraphobia, social anxiety, OCD, GAD, depression, alcohol abuse and sex disorders. This is a very introductory book, however, and Hofmann touches on these various disorders very briefly. Is there anything like this but with a bit more content?
Any help will be greatly appreciated.
Cheers!
Best,
Marc
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You may wish to explore "Doing CBT" by David Tolin. It articulates the core principles and components of CBT extremely well, and how to apply them in treatment for a wide range of psychological disorders, including schizophrenia.
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would like some research on gap and knowledge in current CBT treatment of depression
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Use the link and you get the whole procedure for depression from the CBT school.
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In psychology, we have many approaches to base our evaluation and treatment of a patient, such as psychology of education, community psychology, social psychology, humanistic approach, cognitive-behavioural approach, neuropsychological approach, industrial-organizational approach, psychodynamic, etc. I get that some approaches don't fit with the level of target/observation (e.g. I/O psychology for a single mother at home dealing with major depression), and that each one is a tool in the toolbox for a specific need and objective, but I ask for a possible integration of similar or potentially complementary approaches (neuropsy with TCC or humanistic with ecological model of Bronfenbrenner confirmed with neuropsy, etc.). In summary, I am curious of what has been proposed to build a sort of unity with some of the approaches in modern psychology.
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I think that in the practice of therapists, most of whom are physicians (psychiatrists) but can also be clinical psychologists, method-integrating treatment methods have prevailed. Training events and supervision today ensure that new therapeutic approaches and successes are passed on that did not previously exist.
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Masters Thesis based on Treating Depression using Cognitive Behavioral Therapy. I am looking at the efficiency of CBT. I am not sure if we can use Case Studies for Masters Thesis and if so how? Meaning that I know for qualitative study we suppose to really come up with a theory or add to it.
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Whether case study is a suitable approach, and how many you need, will depend on the questions that the research is trying to answer/ explore. Case studies are not usually suitable if you are trying to generalise and formulate new theory, but they are good for exploring a single phenomenon in great depth and providing new insights which can help us to understand theoretical concepts more clearly. This is something to discuss with your Masters Thesis supervisor, who should be able to help you work out the best approach.
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I am conducting a review of literature these days of CBT interventions using electronic media. I cant find a simple classification of these medias and was wondering if someone can kindly help me?
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Do anyone mention it in under a case law where both are stated as coming under the reasonable classification or not?
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Literature would tell that CBT is one of the widely used and researched therapy, but there are also claims that it has already lost its efficacy throughout time.
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Are you referring to paper by Johnsen and Friborg? :)
They point out in it some possible factors:
- declining adherence to therapy manuals
- declining of the placebo effect
- varying skills of therapy founders/original users and other users
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I'm working on using these 3 modalties to assess the impact of counselling and pyschological interventions when working with women living with FGM
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I would check PTSD research. I would recommend Bessel van der Kolk: "The body keeps the score". He gives a good overview about the attachment theory, trauma and treatment. The book is based on research, but it reads like fiction. Especially with the painful procedure, there will be affective disruption and because the family may have not prevent or even encouraged to do it, there may be major affect issues. I am not sure if you can deal cognitively with it. Sincerely Markus
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Listings of therapy components are needed to fit intervention descriptions onto. I will not define 'components' here to avoid an unwanted narrowing of responses.
Many thanks!
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Hi Jennifer,
I am aware of Michies behaviour change taxonomy
and the UCL competence frameworks may provide what you need http://www.ucl.ac.uk/pals/research/cehp/research-groups/core/competence-frameworks
Or you can make your own condition-specific taxonomy beginning with a review of the literature before examining consensus for each component using a Delphi survey. This is what I did.
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I am searching for studies presenting case studies or some techniques of spiritually/religiously integrated therapy used for the treatment of OCD. But, I couldn't find any study on this topic. I wonder whether or not there is any research on spiritually integrated psychotherapy for OCD. If so, which techniques or process does such a therapy include for treatment of OCD or scrupulosity?
With that said, is there anyone who use any religious centered techniques of CBT/ERP/ACT or Mindfulness based therapies for scrupulosity?                    
I really need your help and suggestions on this topic.
I am looking forward for your help and suggestions. Thank you.
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Spirituality/R
Generally speaking, spirituality plays a pivotal role in promoting physical and behavioral health. The positive therapeutic effects of spirituality in various health settings as an effective technique in improving the wellness of the patients has been reported in many studies ( (Koenig, 2009). As you have pointed out , the application of spirituality can indubitably influence the recovery of the patients suffering from  acute stress, depression, suicide, anxiety, and substance abuse. The following may hopefully shed light on the issue you are looking for.
Best of luck,
R. Biria
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I am looking for full dissertations of reviews which have made use of the Downs & Black CMSQ in order to get some sort of structure as to how to present the results. 
I am currently busy with a systematic review on the efficacy of homeopathic treatment for PMS and would appreciate any assistance.
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We used the Downs & Black (1998) Quality Checklist in a systematic literature review for  the Swedish Board of Health and Welfare. We modified a couple of items due to the nature of our research, but it should still be informative.  You can access it here: http://www.socialstyrelsen.se/publikationer2015/2015-1-17
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I am developing a compound that has been shown to treat respiratory depression, and improve oxygenation in the presence of anesthetic agents I am seeking an expert in anesthesiology and sleep disordered breathing for the proposed treatment of respiratory depression in surgical patients with disordered breathing conditions (e.g. OSA) to collaborate on the development program. Feel free to contact me directly at patricksimms2@gmail.com
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Thank you Lisa 
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I am planning a meta-analysis of patient drop-out in psychotherapy. This would include both randomised trials of psychotherapy interventions which report drop-out rate, and naturalistic/observational studies of drop-out in routine psychotherapy which test various predictors of drop-out, for example alliance (Sharf, Diener & Primavera).
I understand that I can assess risk of bias and study quality in randomised trials using various tools, for example the Cochrane Foundation's Risk of Bias tool, and that similar tools exist for assessing quality in observational tests of interventions which may not be randomised (cohort or case series studies) e.g. Cochrane's ROBINS-I tool (Sterne et al 2016). However, this still assumes an intervention is being tested and looks for bias that could affect that conclusion.
I am less sure what I would assess in a process-outcome study that examines predictors of drop-out that would affect the results. Allocation is not an issue, although blinding of raters could be, e.g. keeping any raters blind as to the drop-out status.
Is there a pubished or unpublished tool which can be used to assess the quality of process-outcome studies?
Thanks in advance.
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Dear Alex,
A meta-analysis of drop-outs in psychotherapy is far from easy. Implementation of bias tools does work only for known and reported bias items. However, quite a few bias-items haven't been mentioned by many authors. Let me summe up some of these: age and gender, support of key figures, type of psychotherapy and the total combination of therapeutic factors as there are medication, expectation before start of therapy, trust in the therapist, disorder and its history of possible failed therapies, training and experience of the therapist.
Let me mention two of the studies I was involved in: In a randomised study on effectiveness of CBT, medication, skills training and two sessions of a psychiatrist trust in the psychiatrist appeared as significant effectiveness factor, more effective than  other studied factors. In a second RCT on therapy of voice hearing patients with chronic psychosis the drop-out rate of HIT an integrative form of therapy was 9% during treatment rising to 16% at 18 months FU. These numbers are fairly good against around 70% in medication and around 30% in CBT. Relevant factors in tis study were faith and trust in HIT and therapist and family support.
So, screen for the hidden factors and filter for their impact.
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Please, I need to find evidence about the effectiveness of Rational Emotive Behavior Therapy (REBT) to treating disruptive behavior disorders in children and adolescents (guidelines, RCTs, reviews or meta-analyzes, as well as any other information). Thank you very much.
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Gonzalez, J. E., Nelson, J. R., Gutkin, T. B.... et al. (2004). Rational Emotive Therapy with Children and Adolescents: A meta-analysis. Journal of Emotional and Behavioral Disorders, 12(4), 222-235. 
Reviewed 19 studies meeting criteria; Findings: the largest effect of REBT was on disruptive disorders. 
Good luck!
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What is the appropriate formula for determining sample size in comparing three groups of study population.
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The PASS 15 program has a Multiple Comparisons of Proportions for Treatments vs. a Control. If you have a control group you could try this. 
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I wonder whether there are scholarly attempts to compare the ABC (Activating Event, Belief, Consequence) framework in Cognitive (Behavioral) Therapies with the ABC (Antecedent, Behavior, Consequences) framework in psychotherapeutic applications of Applied Behavior Analysis (ABA)? This question sounds somewhat silly given that the Cognitive school emerged as a critique of "hard" behaviorism in the historical context. But the question seems relevant given that there is an upgraded behaviorism (which incorporated RFT for instance). I have some ideas yet want to discover whether the question is already addressed somewhere.
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The "ABC" parallel is meaningless. It's just easy to use the first letters of the alphabet as an acronym. However, in both cases "A" refers to that which precedes and causes some sort of reaction.
You can place both "ABC" models on the SORC sequence, though of course that one isn't as "pretty."
S = Stimulus. Same as Antecedent or Activating Event
O = Organism (anything happening inside the creature being observed). This has no parallel in the radical behavioral ABC model, which views the mind as a "black box." In the cognitive system, it would include Beliefs.
R = Response. Same as Behavior. Most of the Consequences in the cognitive model would correspond to this. If, for example, I respond to my belief that I am unlovable by avoiding school dances. Or if I respond to my belief that I cannot survive a situation by developing intense fear, accelerated heart rate, etc.
C = Consequences. Same as consequences in the behavioral model. Some of the Consequences in the cognitive model might correspond to this. But the main focus is on reinforcing and punishing outcomes.
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The polyvagal theory could imply for me that "for humans (and social mammals) the most adaptive stress-response is social communication and self-soothing. There are exceptional situations still nowadays, when flight-or-fight response is useful, but in most of our distressing everyday situations, agressive-defensive behavior is costly although we are trained to use it more often than necessary, and we are untrained to use social engagement, when it could be more helpful". 
Can this opinion on homeostatic responses fit to some other theories, regarding 1) health and placebo, 2) communication 3) body-mind connection, 4) emotions? Could you recommend papers that help to examine these implications?
1)  Can placebo-effect be (at least partly) explained by the polyvagal theory? One evolutionary background of placebo was thought to be that the phylogenetically newest (from the times when our linage started to form social groups) immune reactions are metabolically expensive, therefor only in the perceived social support they are switched on (Humphrey, 2002). Otherwise, in the lack of sufficient social support, more ancient immune responses are activated (from the heritage of reptiles e.g.) which serve to move less and allocate the stored metabolic energy on healing wounds or infections (pain, sickness behavior) (Straub, 2012). Is it possible, that these newer, more effective and more expensive immune responses are activated by the social engagement system? Is it possible, that the modern civilized individuals receive less social input than their ancestors in hunter-gatherer tribes, and thus their neuroceptive system is chronically switched to ‘lonely survivor’ mode, enhancing ancient neuroimmune responses which are not adaptive any more to our biogenetical evolution (chronic pain, autoimmune diseases)?
2) Regarding behavior-responses, is the polyvagal theory connected to the model of non-violent communication, in that the adaptive communication strategy for humans in most of the cases would be empathic connection (Rosenberg, 2003)? Could chronic violent communication have a negative effect on psychosomatic health through the suppression of the social engagement system and the activation of sympathetic system?
3)  Regarding neuroception, beside the empathic presence of an other person, to which extent can I ’stand by myself’, talk to myself and shape my inner dialogue so that I feel socially supported? Are body awareness, as an internalized attention from our caregivers (Bakal, Coll, & Schaefer, 2008), self-compassion, health behaviour enhanced by the social engagement system, and inhbitied by the more ancient stress responses?
4) How the activation of the three vegetative system is connected to emotions, e.g. are anger, fear, happiness connected to different pattern of neovagal, sympathetic, and archeovagal activation? Can the polyvagal threefold model be related to the sevenfold model of basic emotions of Panksepp (Panksepp, 2005)?
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Thanks Benedek for your thoughtful questions. I would like to throw the ball back to you asking you and others carefully to evaluate the literature on RSA and social engagement:
1) From the several meta-analyses and individual studies I have reviewed, it appears that the effect sizes of this relationship are small (Cohen's d approximately 0.3 overall). This means there is an overlap of distributions of those competent vs. less competent in social engagement of about 90% regarding RSA differences. Given the publication bias that positive findings are consistently overreepresentedvin the literature, the author bias of those interested in this relation being disposed to find positive effect sizes, these biases also indicated in some of the meta-analyses by statistical tests, and the weak relations found anyhow, how convincing is the notion that RSA is a highly relevant biological marker of variations in social engagement? If this relationship was so important from an evolutionary standpoint, shouldn't the effects be clearer?
2) Respiration rate and volume are known to confound the relation between RSA and cardiac vagal tone, particularly within individuals between also sometimes in analyses across persons. These respiratory parameters may also be influenced by aspects of social engagement (e.g. We know breathing is very sensitive to variations inemotion and psychological tasks). Very few of the relevant studies have taken these respiratory parameters in account when examining RSA and aspects of social engagement, or have appropriately adjusted for respiration when they have. Is this not a necessary first step before making assumptions about the importance of the vagus for social engagement?
3) Regarding RSA as a marker of individual differences in cardiac vagal tone, can we really assume it is just that? There are multiple indications that at very best, it is a moderate index of cardiac vagal tone and may be worse than resting heart rate (I have cited numerous references in my own ResearchGate question/blogs). At best, RSA is a marker of vagal influences upon heart rate, not even a maker of parasympathetic effects upon other aspects of cardiac function, e.g. how excitable the heart ventricles are or the level of contractility, not to mention that individual differences in RSA do not correlate strongly with individual differences in markers of bronchial or gut vagal activity. So how are we to believe that RSA is a good index of general level of vagal tone that affects the whole organism, when individual organ systems are not correlated? And that is the clear implication of the social-engagement/RSA literature.
4) It has been known a very long time that the parasympathetic nervous system subserves a very broad range of physiological functions--in regard to the cardiovascular system making sure that enough oxygen quickly gets to the necessary parts of the body that are active at different tasks, e.g. physical exertion, eating, lovemaking, speaking, etc. That this extends to biological substrates of psychosocial functioning is nothing at all new. What is new is the fixation upon the vagus as the predominant player. Interesting in the 70's and 80's, it was all about the sympathetic nervous system. Our psychobiological functioning is far more complex than even the workings of these two systems, with lots of local events at the organ levels integrating and interacting with autonomic influences to determine dynamic functioning. So is there sufficient grounds to hypothesize that the vagus is somehow the primary player, especially since the main theoretical assumptions appear false and the applied empirical,evidence is weak at best?
Very frankly, I guess I see psychologists attempting to grasp at biological explanations of behavior and psychological functioning that are far too simplistic. They become confused by varying opinions among different authors because they have not ventured beyond the "psychological vagal tone" literature. They are right to assume that the vagus plays some role in the body and brain's rapid responses to life's vagaries (so do sympathetic processes and more complex interactions with local factors, often giving rise among physiologists to the idea that the heart has its own little brain and the gut too). So shouldn't we rise from this vagal fixation and simultaneously explore more parameters than RSA (even heart rate, by which RSA is determined fails to be reported in most of these RSA/social engagement studies and could have substantial bearing on interpretation of findings)?
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Please read the first article that a patient does not need to have a traumatic event to cause a severe mental disorder. It depends on how badly organ functions were hurt.
It also does not mean after a traumatic event makes the treatment becomes harder. Please read the second article. The key is the right treatment used?
For phobia, NLP works. Jump out of the box, there are more solutions with excellent results.
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@ Meghna Singh, Yes, Thnks for pointing out. The miracles are more than your list. However, the ancient medicines which can treat diseases well be labeled "Not scientific". Only because it likes the nature that there are no two rose flowers are exact the same, no two snowflakes are the same.
This "not scientific" makes many minds blinded persons keep away from Chinese medicine and ended organ failure, etc.
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Is anyone aware of how to score the STRAPR measurement by Goldstein et al? I'm having difficulty finding scoring information for a project I've been working on. 
Thanks! 
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I understand your difficulty. You should directly contact Pr. Goldstein: 
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I'm looking for the benefits of singing in a choir for the adults
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Wow! Thanks all for the articles.  I am a choir member of our church and i will challenge my friends to consider joining the choir.
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Does anyone know about studies that compared a combination of cognitive defusion and cognitive restructuring, with cognitive restructuring alone, and/or with cognitive defusion alone, regarding their effects on believability of targeted thoughts?
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I don't think there's necessarily a conflict at the level of technique and I think it's necessary to pick a foundation as to the rationale. Is believability your end goal, if so, what is the purpose of impacting on that? I have some Relational Frame Theory ideas about that. 
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Children leading normal life but having tendencies of anxiety or have anxiety due to various reasons but are still not clinically diagnosed, how to treat them using Counselling.
Which counselling technique is best?
I am using Becks Anxiety Inventory to screen adolescents. Is this the right scale to use before starting with my project?
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Behavioral treatments have generally proven more helpful than non-behavioral treatments for children and adolescents.
The BAI is ok, but seems to load fairly heavily on physiological arousal (e.g., panic) symptoms.  Alternatives include the Revised Child Anxiety and Depression Scale, the Screen for Child Anxiety Related Emotional Disorders, and the Multidimensional Anxiety Scale for Children. 
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I am in search of tasks with high test retest reliability and otherwise sound psychometric properties.
Although I am most interested in disinhibition of behavior and sensitivity to interoceptive cues, I am open to the study of other constructs.
I JUST WANT A RELIABLE TASK! :) Thanks in advance
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Nope, I don't really mean that- I'll email you here in a bit. I almost wish I could say the same about not having enough experience with humans (ahh so much variability) ... if only we could cage them and put them on food restriction (JOKING).
Haha. I suspect the high quality answers will come out in our email exchange.
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We measured CD4 levels over 12 months, and the levels are skewed at 2 of the 12 data points. In running a longitudinal analysis (e.g., mixed models) with CD4 as the outcome, should I correct for skew for only those 2 data points, or for all 12 points so that the metric is similar?
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Thanks, that certainly makes a difference - I'll take a look at the lme4 package.
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Most attention has been toward improving the positive symptoms of schizophrenia. Medications are especially effective for positive symptoms. Negative symptoms often are what holds pts back from a productive life. I am looking for information/articles about this.
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Here are some recent work I am aware of that may be partly relevant to your interest:
Schizophr Res. 2014 Aug;157(1-3):182-9. doi: 10.1016/j.schres.2014.05.025. Epub 2014 Jun 10.
The role of dysfunctional attitudes in models of negative symptoms and functioning in schizophrenia.
Quinlan T1, Roesch S1, Granholm E2.
Author information
 
Abstract
Neurocognitive impairment is associated with negative symptoms and poor real world functioning in schizophrenia. Dysfunctional attitudes (e.g., "If I fail partly, it is as bad as being a complete failure") have been found to mediate these relationships between neurocognition and negative symptoms and functioning. In this study, these relationships were examined in 179 participants with schizophrenia or schizoaffective disorder using structural equation modeling. Defeatist attitudes were found to mediate the relationship between neurocognition and negative symptoms but not the relationships between neurocognition and performance-based or self-reported functioning. A full model with the best fit showed mediation between neurocognition and self-reported functioning through two different pathways: One from neurocognition to functional skill capacity to real-world functioning, and a second from neurocognition to defeatist attitudes to negative symptoms to real-world functioning. These results may implicate skill deficits and defeatist attitudes as a separate treatment targets for negative symptoms and functioning in schizophrenia.
Schizophr Res. 2014 Aug;157(1-3):312-3. doi: 10.1016/j.schres.2014.06.002. Epub 2014 Jun 24.
Mindful cognitive enhancement training for psychosis: a pilot study.
Tabak NT1, Granholm E2.
J Consult Clin Psychol. 2014 Dec;82(6):1173-85. doi: 10.1037/a0037098. Epub 2014 Jun 9.
Randomized clinical trial of cognitive behavioral social skills training for schizophrenia: improvement in functioning and experiential negative symptoms.
Granholm E1, Holden J1, Link PC1, McQuaid JR2.
Author information
 
Abstract
OBJECTIVE:
Identifying treatments to improve functioning and reduce negative symptoms in consumers with schizophrenia is of high public health significance.
METHOD:
In this randomized clinical trial, participants with schizophrenia or schizoaffective disorder (N = 149) were randomly assigned to cognitive behavioral social skills training (CBSST) or an active goal-focused supportive contact (GFSC) control condition. CBSST combined cognitive behavior therapy with social skills training and problem-solving training to improve functioning and negative symptoms. GFSC was weekly supportive group therapy focused on setting and achieving functioning goals. Blind raters assessed functioning (primary outcome: Independent Living Skills Survey [ILSS]), CBSST skill knowledge, positive and negative symptoms, depression, and defeatist performance attitudes.
RESULTS:
In mixed-effects regression models in intent-to-treat analyses, CBSST skill knowledge, functioning, amotivation/asociality negative symptoms, and defeatist performance attitudes improved significantly more in CBSST relative to GFSC. In both treatment groups, comparable improvements were also found for positive symptoms and a performance-based measure of social competence.
CONCLUSIONS:
The results suggest CBSST is an effective treatment to improve functioning and experiential negative symptoms in consumers with schizophrenia, and both CBSST and supportive group therapy actively focused on setting and achieving functioning goals can improve social competence and reduce positive symptoms.
TRIAL REGISTRATION:
ClinicalTrials.gov NCT00338975.
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looking at themes for in depth research of
Restructuring of the NHS and improving access to psychological therapies 
CBT is recommended in first instance why, nice guidelines, Layard influence, cost, and assess ability,
Effectiveness of CBT-EVIDENCE rcts, biomedical/biopsysocial where cbt fits
Limitations of cbt-how currently used
struggling to identify sources to narrow effectively any recommended journal sources please,
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How to work with shame, rejection, limitations and intimacy issues that some skin diseases may trigger. 
Also, examples of specific formulation.
Thanks in advance.
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Have a search in research gate for Lance McCracken. Professor of clinical health psychology. Lots of papers on cbt for chronic pain. 
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Very often I'm working with people that are impaired by a traumatic spinal cord injury. People elaborate this loss along some more-or-less-defined phases, that are very alike to the phases of grief.
Usually the period of grief ends with the possibility, for the person, to put his/her resources on new objectives.
However in the case of acquired disabilities the entity of the loss is enormous and may impair each future scenario.
Are there studies, based on a cognitive - behavioural framework, that may help me to better understand how to face these problems?
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Hi Michele,
it's great that you are looking into this. In addition to th literature mentioned above, I would suggest considering the rationale behind and techniques of Acceptance and Commitment Therapy (ACT, for example Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An experiential approach to behavior change. New York, NY: Guilford Press.).
Best regards
Franziska
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I am a PhD student and I'm looking for Italian psychologists, psychiatrists and researchers adopting Behavioural Family Therapy (Faloon's model) for psychotic subjects, because I'd like to be trained in it. Can anyone help me? Thank you.
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Lorenza Magliano has written a number of articles about BFT in an Italian context relating to both client and family outcomes and implementation
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I am working with a team to create a web-based CBT platform. We would love to be able to adapt an existing model that had already been validated. I would very much appreciate any help or direction on this! Thank you!
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Dear Elnera, I recommend this book:
Andersson, G. (2014). The internet and CBT: A Clinical Guide.
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Palo-Alto approach is one of the branch of brief therapy. It was developed at the MRI in Palo-Alto. It used constructivism, systemic, cybernetics and other concept as pragmatics of communication, double bind, paradox. I would like to find out publication, studies about the efficiency of the approach for human problem solving. These could be qualitative or quantitative studies. 
Thanks
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Marc, te adjunto el link con un articulo de mi autoria sobre el tema:
Exitos con tu investigación.
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If a couple recorded their daily interactions for a week (in their kitchen & living room), this footage would help a counsellor understand the problems of the relationship, and could help the couple see their relationship from a fresh perspective. The technique could be applied to range of therapeutic situations. Has there been research on this kind of approach?
Edit (after 2 answers received): the question asks whether research on this has ever occurred. The criticisms offered in the 2 answers so far are reasonable. Would their predictions be borne out in an experimental trial? That is one of the empirical questions I'm interested in. 
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There has been a long tradition of using home videos in therapies of early infant-caregiver relationship disturbances. After a few minutes, parents and children usually forget about the camera and show how they interact, eat and play in everyday life. Therapists discuss the video recordings with the parents in order to reinforce the positive moments of the interaction. Fore more, see McDonough (1993) in Zeanah (ed) Handbook of Infant Mental Care. 
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For example, using the Aberrant Salience Inventory (ASI)? 
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Cognitive Remediation Therapy appears to be a much recommended approach although aberrant salience is only infrequently measured. ( See previous response by B M Evalds-Kvist). Are you seeking to relate the rate of learning to the level of aberrant salience, evaluate the efficacy of therapy in another study...?
Also see:
Gould RA, Mueser KT, Bolton E, Mays V, Goff D:
Cognitive therapy for psychosis in schizophrenia
Schizophr Res 2001; 48: 335-342
Kurtz MM, Moberg PJ, Gur RC, Gur RE
Approaches to cognitive remediation of neuropsychobiological deficits in schizophrenia
Neuropsychol Rev. 2001;11 (4): 197-210
Cognitive Rehabilitation for Schizophrenia and the Putative Role of Motivation and Expectancies
Dawn I. Velligan1,2,
Robert S. Kern3 and
James M. Gold4
1To whom correspondence should be addressed; e-mail: velligand@uthscsa.edu
 
Abstract
Cognitive rehabilitation (CR) approaches seek to enhance cognitive processes or to circumvent cognitive impairments in schizophrenia in an effort to improve functional outcome. In this review we examine the research findings on the 8 evidence-based approaches to cognitive remediation listed in the 2005 Training Grid Outlining Best Practices for Recovery and Improved Outcomes for People With Serious Mental Illness, developed by the American Psychological Association Committee for the Advancement of Professional Practice. Though the approaches vary widely in theoretical orientation and methods of intervention, the results are, for the most part, encouraging. Improvements in attention, memory, and executive functioning have been reported. However, many persons with schizophrenia are more impaired in real-world functioning than one would expect given the magnitude of their cognitive deficits. We may need to look beyond cognition to other targets such as motivation to identify the reasons that many persons with schizophrenia demonstrate such marked levels of disability. Although a number of current CR approaches address motivation to varying degrees, treating motivation as a primary target may be needed to maximize CR outcomes.
Introduction
Cognitive impairment is a core feature of schizophrenia.1 Deficits in cognitive functioning, including those in psychomotor speed, attention, memory, and executive functions, are thought to underlie the severe functional disability associated with this illness.2–11 This relationship between cognitive deficits and poor functional outcome has prompted the development of cognitive rehabilitation (CR) approaches focused specifically on treating the cognitive deficits of schizophrenia.12--The field continues to struggle to reach agreement in terminology to describe existing CR approaches. The restorative versus compensatory distinction has been popularized in the traumatic brain-injured but not the schizophrenia literature. As not all programs of cognitive rehabilitation aim to “restore” the individual to his or her premorbid state or “restore” the function of neurons and neural circuits, it may be more accurate to describe such programs as “cognition enhancing” efforts, in that they all seek to improve cognitive functioning through a set of specified training interventions. In contrast, compensatory approaches aim to bypass or “compensate” for cognitive deficits to promote skill acquisition or functional outcome.--In the schizophrenia literature there are several independent and competing CR approaches being developed concurrently. These approaches vary in their theoretical underpinnings, methodologies, and targets of outcome. An appreciation of the different theoretical approaches and methods of intervention, and their corresponding strengths and weaknesses, may inform future efforts.--Previous Reviews
The CR literature in schizophrenia has been, and continues to be, a difficult literature from which to draw firm conclusions. Studies vary considerably in teaching methods, patient samples and sample sizes, outcome measures, intervention dose (amount of training), inclusion of control or comparison groups, blinded procedures, level of professional education and experience of trainers, and reliance on theoretical models. Even the reviews of this literature vary considerably.13–20 They differ according to criteria for study inclusion, conceptual organization of studies, and interpretation of findings. These range from highly conservative reviews such as provided by Pilling et al.,14 which examined 5 randomized controlled trials in schizophrenia, to more liberal efforts such as those by Kurtz et al.,13 which encompassed the extant literature at the time. Overall, the reviews have been mostly positive, with the exceptions of the Pilling et al. review,14 which was decidedly negative, and Suslow, Schonauer, and Arolt's review20 of attention studies. We focused our review on 8 evidence-based approaches of CR. The selection was based on their inclusion in the 2005 Training Grid Outlining Best Practices for Recovery and Improved Outcomes for People With Serious Mental Illness, developed by the American Psychological Association Committee for the Advancement of Professional Practice.21 These approaches have been used in clinical trials of schizophrenia and best illustrate the differing emphases in this continually developing area of rehabilitation. To our knowledge, this is the first review article to include a presentation of all 8 approaches. The second aim of this review is to stimulate a discussion on the role of motivation in CR. A section at the end of the article deals specifically with this issue. When appropriate, motivation issues are discussed within the context of the CR approaches presented in this review.--Integrated Psychological Therapy (IPT22) was one of the first clinically based CR programs that was specifically designed for persons with schizophrenia. IPT is based on a building-block model that assumes that elementary, basic neurocognitive functions are necessary prerequisites for higher-order complex social functions. Training is conducted in small groups of 5–7 patients in 30–60 minute sessions 3 times per week and proceeds through 5 subprograms arranged in a hierarchical order according to complexity of function. The first 3 subprograms represent the cognitive training component and include training of abstraction, conceptual organization, and basic perception and communication skills. These are named Cognitive Differentiation, Social Perception, and Verbal Communication. These abilities are believed to be prerequisite skills, essential for carrying out effective social interactions. The fourth and fifth components represent the behavioral level of social interaction and are similar to skills training approaches used elsewhere.23 These are named Social Skills and Interpersonal Problem Solving. Training is highly structured and manual-driven. Completion of the subprograms is accomplished in about a 6-month period though successful completion of a series of graduated activities.--IPT appears to convey benefits compared with less extensive psychosocial treatments on social functioning. However, the beneficial effects of IPT on neurocognition are more equivocal. Further, it is not clear from the studies of IPT whether changes in neurocognition are necessary to produce changes in social functioning.--In one of the more methodologically rigorous studies of IPT, Spaulding et al.24 tested the effects of the cognitive component of IPT on social problem-solving ability in a sample of schizophrenia inpatients. Participants were randomized to 2 groups: a group that received the first 3 subprograms of IPT plus skills training versus a group that received supportive therapy plus skills training. Hence, the primary difference between groups was the IPT cognitive training component. The results from the study showed a differential treatment effect favoring the IPT plus skills training group on the primary outcome measure of interpersonal problem-solving (AIPSS). Interestingly, the study produced relatively few differential treatment effects on cognition. Only 2 out of 13 neurocognitive variables (Span/Continuous Performance Test [CPT] and Wisconsin Card Sorting Test [WCST] random errors) showed a differential treatment effect. However, the IPT plus skills training group did show significant pre-post gains on 7 of the 13 measures compared with 4 out of 13 in the control group. Somewhat paradoxically, the results suggested that participation in the neurocognitive component was necessary to enhance gains in social problem-solving ability, yet there was little evidence of a differential treatment effect on neurocognition. A failure to find support for the “building block” model of IPT has been found in other studies as well.25--Cognitive Enhancement Therapy
Cognitive Enhancement Therapy (CET) is based on a neurodevelopmental model of schizophrenia that proposes that disturbances in neurodevelopment result in delays in social cognition. Social cognitive milestones such as perspective taking are the focus of treatment. According to the model, the brain's neuroplasticity reserve can be enriched through cognitive experiences provided through training. The conceptualization of training within CET was influenced by Ben-Yishay and colleagues'26 work with traumatic brain-injured patients, Brenner's IPT,22 and contemporary theories of human cognitive development. The emphasis in training is to shift from concrete cognitive processing of information to “gistful” spontaneous abstraction of social themes. There are 2 main components to training: (1) computer-based cognitive exercises that focus on attention, memory, and problem-solving abilities and (2) small group training of social cognition. CET involves social interaction at every stage. The computer sessions are conducted in pairs of patients with the therapist providing oversight. Patients take turns using the computer software programs and assist each other by providing strategies and offering encouragement. The curriculum for the social cognition groups consists of categorization exercises, formation of gistful, condensed messages, solving real-life social dilemmas, abstraction of themes from newspaper articles (eg, USA Today), appraisal of affect and social contexts, initiating and maintaining conversations, playwriting, and center stage exercises (eg, introducing oneself or a friend). The groups involve structured but unrehearsed in vivo social interactions. Sessions include a homework review, a psychoeducation topic, an exercise by a patient or pair, feedback from other patients and coaches, and a new homework assignment based on the education topic. Training is individualized to the cognitive-processing style deficit of the participant.
CET is one of the more time and resource demanding of the CR programs in schizophrenia. In a 2-year randomized trial of CET,27 participants in the CET group received 75 hours of computerized training on attention, memory, and problem-solving exercises combined with 56 sessions (1.5 hours per week) of training on social cognition exercises. Participants were selected based on meeting criteria for cognitive disability, which consisted of impairments, functional disabilities, and social handicaps associated with 1 of 3 dysfunctional cognitive styles, and the criteria for social cognitive disability. At the 12-month follow-up assessment, differential treatment effects of CET compared with enriched supportive therapy (EST) were found for composite indices of neurocognition and processing speed, and marginal differences were found for the behavioral composites of cognitive style, social cognition, and social adjustment. At the 24-month assessment, differential effects were found on all composite indices. The control group was not matched to the experimental group for amount of training exposure, which makes it difficult to interpret the contribution of participation in a structured rehabilitation activity. Also, the neurocognitive battery used to assess outcome shared similar methods with the computerized training tasks. Hence, the study's findings could be due to shared method variance and not the training per se. Still, the reports from this group over the years have been highly encouraging. The conceptual model underlying CET is well developed, and the approach targets a deficit highly relevant to the overall well-being of persons with schizophrenia.--Neurocognitive Enhancement Therapy
The Neurocognitive Enhancement Therapy (NET) program of Bell and colleagues28 is similar to CET, except that the focus is on work rehabilitation. Like CET, NET includes computer-based cognitive training. NET uses software programs developed specifically for this group by Odie Bracy, which are similar to that used by Hogarty and colleagues27 and were specifically designed for use in the treatment of persons with compromised brain function. They have been widely used in the rehabilitation of persons with traumatic brain injury, and in more recent years they have been used with persons with schizophrenia. The software programs include a number of specific training exercises that differ by cognitive target and difficulty level. Training begins with relatively simple exercises and proceeds to more complex ones. During training, participants work at their own pace and move from one training exercise to another. Once a participant attains 90% accuracy at a given difficulty level, the parameters of the task are changed to make the task more challenging and enhance the motivation to perform optimally. Training focuses on attention, memory, and executive functions. The other components of NET include biweekly feedback based on results from an on-the-job assessment, using the Cognitive Functional Assessment scale, and participation in a weekly social processing group. The Cognitive Functional Assessment scale is a measure of cognitive function that consists of ratings of attention, memory, and executive functioning while the participant is performing his or her job. Feedback is provided to participants during their weekly work therapy support group.--In a study of 65 schizophrenia or schizoaffective disorder patients, participants were administered a baseline cognitive assessment and then stratified by level of cognitive impairment and randomly assigned to NET plus work therapy versus work therapy alone.28 Participants received up to 5 hours of computerized cognitive training each week over the 26-week protocol. At the end of training, the NET plus work therapy group showed significantly greater gains than the work therapy alone group on measures of executive functioning, working memory, and affect recognition. Approximately 60% of participants in the NET plus work therapy group showed improvement in neurocognitive performance and were 4 to 5 times more likely than participants in the comparison group to show improvements in neurocognitive function of a large effect size (Cohen's d > .80). Improvements in working memory were, perhaps, most impressive. The percentage of patients showing working memory performance within the normal range changed from 45% to 77% in the NET plus work therapy group, compared with a decrease from 56% to 45% in the work therapy alone group. Moreover, Bell et al.28 found that patients participating in NET plus supported employment had better vocational outcomes than those in supported employment alone.
This group has conducted 2 long-term studies to evaluate the effects of adding NET to vocational programs. The first study, described above, was conducted in a VA setting with participants placed at jobs within the VA.28 A second study,29 which is ongoing, used a community-based supported employment program. Training in the second study was twice as long (12 months). Preliminary data on 54 participants who completed training revealed the NET plus supported employment group to show significantly greater improvement on executive functioning and trends in the expected direction on the other cognitive factors (working memory, thought disorder, and visual and verbal recall). Employment data attained from these 2 studies showed that participants assigned to NET either maintained or increased the number of hours they worked during the follow-up period. Participants receiving only work therapy or supported employment showed a decrease in hours worked. Results were similar when considering the percentage of participants employed. The group differences were more modest in the VA-conducted study perhaps because of the high rates of employment with veterans placed in noncompetitive jobs. In the supported employment study with preliminary data on 43 participants who completed the 12-month follow-up period, the differences were more marked. Twelve months after training, 57.5% of participants in the NET plus supported employment group were still employed compared with only 21.0% of participants in the supported employment alone group. The results from the latter study provide preliminary evidence that the beneficial cognitive and vocational effects of NET can be extended to competitive jobs in community settings.
Individual Executive Functioning Training/Cognitive Remediation Therapy
Another approach to cognitive rehabilitation in schizophrenia is based on an understanding of the cognitive processing deficits common to persons with schizophrenia and how these are linked to deficits in complex behavior such as social functioning. An example of a formal clinical program using this approach was developed in Australia by Ann Delahunty and Rod Morice (1993)30 and has been adopted for use in the United Kingdom by Til Wykes and colleagues, and it is now referred to as Cognitive Remediation Therapy (CRT).6,31,32 The training program targets deficits in executive processes and consists of 3 modules: cognitive flexibility, working memory, and planning. This program places a strong emphasis on teaching methods and uses procedural learning, principles of errorless learning, and other evidenced-based methods. In contrast to CET and NET, this program uses paper-and-pencil exercises for training instead of computerized tasks, and there is greater emphasis placed on the trainers' role in working with patients during the cognitive exercises. Similar to CET and NET, training proceeds through a series of exercises, graduated in level of difficulty, beginning with simpler exercises and progressing to more complex ones. Training is individualized and proceeds at each subject's own pace. The exercises share conceptual features with neurocognitive tests, but they are methodologically different to reduce shared method variance between training exercises and outcome measures. For example, during training for cognitive flexibility, participants are asked to cross out all even numbers, then odd numbers. This requires maintenance and then shifting of cognitive set, similar to that required on the WCST but distinctly different from training to the test.--Results of this approach have been mostly positive. In a study using only the cognitive flexibility module, Delahunty et al.30 found improvements in WCST performance immediately after training, and the gains were maintained at a 6-month follow-up assessment. In a separate study using all 3 training modules, Wykes et al.33 found evidence for a differential treatment effect favoring the cognitive training group over a control group that received intensive occupational therapy. Training was conducted 1 hour per day, 3 to 5 days per week, over 40 sessions. A differential training effect was found on measures from the WCST and a planning test (modified 6 elements). An interesting secondary analysis of the data showed that participants who met a certain threshold for improvement on cognitive flexibility showed improvements in social functioning within the 3-month duration of the trial. In a 6-month follow-up study of 33 outpatients to address the durability of CRT effects, Wykes et al.32 examined stability of gains on 3 primary cognitive outcome measures (WCST, Digit Span, and Tower of London) and a number of secondary cognitive outcome measures. Of the primary outcome measures, only Digit Span performance showed durable gains with CRT over the 6-month follow-up. For the secondary outcome measures, there was a differential treatment effect favoring the CRT group on measures within the memory domain, but not the cognitive flexibility or planning domains. The results suggest good durability for improvements in memory but not for the other 2 targeted domains.
Neuropsychological Educational Approach to Rehabilitation
The manualized Neuropsychological Educational Approach to Rehabilitation (NEAR) program developed by Medalia34 is founded on teaching techniques developed within educational psychology that are designed to promote intrinsic motivation and task engagement. The NEAR conceptual model favors a top-down approach that emphasizes higher-order, strategy-based methods of learning over drill-and-practice exercises that focus on learning of elementary cognitive skills (bottom-up approach). Training involves participation in computer-based cognitive exercises that are designed to be engaging, enjoyable, and intrinsically motivating and that require the recruitment of several cognitive skills within a contextualized format.--Medalia et al.35 investigated a component of the NEAR program in a sample of 54 inpatients with schizophrenia. Participants were randomly assigned to problem-solving remediation, memory remediation, or a control group. CR participants worked with either problem-solving or memory-enhancing computer games in 2 weekly 25-minute sessions for 5 weeks. The group assigned to problem-solving training worked with the “Where in the USA is Carmen Sandiego?” software program. This program is colorful, cognitively challenging, and provides strategy-oriented feedback. Memory training involved a less engaging computer-based program (Memory Package software) that emphasized verbal and visual memory. Participants in the problem-solving group improved to a greater extent in problem solving than those in the memory or control groups. However, participants in the memory training group did not show any differential training effect on memory. The effects of remediation on problem solving persisted 4 weeks after training.36--In an earlier study Medalia et al.37 examined the effects of individual computer-based training of attention using a software program developed out of Ben-Yishay's lab.26 The study included 54 inpatients with schizophrenia who were randomly assigned to computer-based cognitive training using the Orientation Remedial Module or a control condition that involved the viewing of video documentaries. Training within each module followed a test-train-test sequence and lasted approximately 20 minutes. The tests administered at the beginning and end of each session measured visual reaction time. In between, participants worked on 1 of 5 training modules. Progression through 1 module was believed to build skills necessary for successful mastery of later ones. After 18 sessions the results showed significantly greater improvement in the cognitive training group compared with the control group on the primary outcome measure, a computerized continuous performance test. Results of the studies conducted by Medalia et al. suggest that intrinsic motivation may be an important consideration for promoting rehabilitation success.--In an interesting extension of their work, Medalia and Richardson38 reported on moderating variables of rehabilitation outcome. Data were collected from 3 of their studies (total N = 117) that used NEAR or elements of it. Three broad categories were examined: patient characteristics, illness characteristics, and treatment characteristics. Patients were dichotomized as “improvers” or “non-improvers” according to whether they showed reliable improvement in at least 1 cognitive domain. The change index was calculated by dividing change scores on each dependent measure by its standard error of measurement. The results showed that illness factors were least related to training outcome. However, patient and treatment factors differentiated improvers from non-improvers. Specifically, treatment intensity, type of cognitive remediation program, therapist qualifications, patient's motivation for treatment, and baseline work habits differentiated improvers from non-improvers. These findings suggest that a host of variables, including motivation and dosing, may be important considerations in formulating CR training.--Attention Process Training
Attention Process Training (APT) was developed by Sohlberg and Mateer39 as an approach to CR for persons with traumatic brain injury. Four areas of attention are targeted for training: sustained, selective, dividing, and alternating attention. Four different types of material (auditory and visual cancellation tasks, mental control tasks, and daily life tasks) are used. The training exercises are arranged in hierarchical difficulty; participants progress through training exercises after establishing mastery at each stage. Like CET and NET, APT follows a building block approach. Skills acquired in earlier stages are viewed as prerequisite for skill development in later training stages.--Though APT has been used successfully in studies of brain-injured patients, there is little data on its efficacy with schizophrenia patients. Lopez-Luengo and Vazquez40 examined the efficacy of APT in a sample of 24 schizophrenia patients. Participants were randomly assigned to APT or treatment as usual. Participants in the APT group received training twice per week; however, the number of weeks of training varied considerably across patients (range = 8 to 76). Training sessions were on the average less than 1 hour. A large number of attention measures were included in the battery. These were specifically designed to capture the 4 areas of attention that were targets of training in APT. Measures of memory and executive functioning were also included. Despite the number of measures, the study yielded only 1 significant finding on attention, and it was in the unexpected direction (the control group showed greater pre-post improvement than the APT group). The APT group did show a differential treatment effect on the measure of executive functioning (WCST) but not on the Spanish-translated version of the California Verbal Learning Test (CVLT) (the measure of memory). There was no statistical control for the number of comparisons in the study, so the WCST results have to be viewed somewhat cautiously. In sum, the findings are largely negative from this study.--There is a small study of APT in schizophrenia that examined APT and Prospective Memory Training (PROMT).41 Three patients were assigned to cognitive rehabilitation training using APT and PROMT; data for 3 other patients were drawn from the University of Pennsylvania Schizophrenia Center database. APT preceded PROMT training. Training was conducted 2 times per week in 1-hour sessions over a 5 to 7-month period. The 3 subjects who received training were administered an attention battery before and after training. There were no formal analyses of the data. Subjects #1 and #3 were described as showing improvement on measures of sustained attention (cancellation tasks). Subjects #1 and #2 were described as showing improvement on the measure of divided attention (auditory consonant trigrams). There were no other noteworthy observations of pre-post differences for any of the three patients on the other attention measures (Digit Span, Stroop, CPT).--Attention Shaping
Behavioral-based approaches for modifying behavior, even cognition, are not new.42,43 Shaping involves the differential reinforcement of successive approximations toward a target behavior. Behaviors that approach the desired target are reinforced; nondesired behaviors are not. Initially, training focuses on behaviors that have a high likelihood to occur within an individual's existing behavioral repertoire (eg, sitting up for 30 seconds). Once that behavior becomes established (ie, occurs regularly), the criterion for reinforcement is advanced so that the individual must perform a behavior that is closer to the end goal. The new behavior is then selectively reinforced, and these steps are repeated until the target behavioral goal is attained. Behavioral shaping procedures share methodological procedures with other training approaches such as errorless learning. One key difference is that in shaping, training is not explicitly designed to prevent mistakes or undesired behaviors from occurring, whereas in errorless learning the trainer takes active steps to prevent them.--Silverstein et al.44,45 demonstrated that a group of 6 treatment-refractory schizophrenia inpatients' attention span during participation in a skills training group could be improved by pairing primary or secondary reinforcers (such as tokens) with the desired behavioral response. A set of individualized verbal and nonverbal behaviors was targeted for training. Nonverbal behaviors included behaviors such as keeping eyes open, keeping head up, and making eye contact with the group leader. Verbal behaviors included responding within 5 seconds and making spontaneous comments. After a baseline assessment and identification of individualized attention goals, shaping procedures were initiated during the group. Two observers who were not involved in conducting the group recorded the frequency of target behaviors during 15-minute intervals. After each interval, patients who met or exceeded their target goal received a token that could later be exchanged for 25 cents. Shaping procedures initially targeted relatively simple attention goals (eg, eyes open for 30 seconds) that were easily met, and they increased in difficulty as mastery was attained over time. Results indicated that all participants in the study showed significant pre-post gains in attentive behavior. Similar positive findings are reported from earlier studies with severely impaired schizophrenia patients.42,46--Behavioral shaping is the only evidence-based cognitive rehabilitation treatment for severely impaired, treatment-refractory schizophrenia patients. One concern with behavioral shaping procedures is that training gains are lost once reinforcement is discontinued. However, there is some data to suggest that gains may be more durable in clinical settings than would be anticipated.42 The durability may be due to the fact that in treatment settings the reinforcing qualities of the originally trained-on reinforcer (a token) are transferred to other, perhaps more potent reinforcers (eg, social praise for engaging in the desired behavior, increased self-efficacy on the part of the patient). In the Silverstein et al. studies, patients may attain greater mastery and sense of success as they are able to meet behavioral goals through proscribed shaping procedures. Interestingly, though the behavioral shaping program initially begins with primary and secondary reinforcers aimed at gaining traction on the target behavior (ie, attention span), a secondary outcome of training may be improvement in self-efficacy and self-esteem. Arguably, promoting self-efficacy through training success is a goal in virtually all cognitive rehabilitation training programs.--In an interesting study with a complicated design, Silverstein et al.47 examined the efficacy of individually administered APT (described above) followed by attention shaping administered within a skills training group. Participants were schizophrenia patients randomly assigned to APT plus attention shaping versus a control condition. The 2 groups were matched for training time. For the experimental group, training included 6 weeks of APT followed by 16 sessions of skills training with attention shaping. For the control group, training included 6 weeks of group treatment followed by 16 sessions of skills training without attention shaping. The behavioral outcome measure was a summary of the daily ratings of attentiveness for each participant. Neuropsychological measures included the Digit Span Distractibility Test, Sustained Attention Test, California Verbal Learning Test, and the Micro-Module Learning Test. The study yielded rather fascinating results. The experimental group showed dramatic improvement on the behavioral observational data of attention versus the control group. After training, the experimental group showed periods of attentiveness of an average duration of approximately 19 minutes compared with approximately 2 minutes for the control group. There were no group differences on the neuropsychological measures of attention, perhaps because of the lack of sensitivity of these measures at detecting behavior change. The study design did not allow for a direct comparison of the specific contributions of APT versus attention shaping, although relatively low levels of attentiveness were observed after APT that increased substantially with attention shaping. The slope of attentional improvement during the attention shaping phase was similar to that observed in previous studies.45--These findings underscore a key conceptual dilemma in cognitive rehabilitation, namely, “What are the most appropriate CR outcome measures?” Wilson,48,49 in her work with brain-injured patients, has noted the poor relationship between cognitive impairment measured by neuropsychological tests and cognitive disability reflected in reduced ability to perform real-world tasks. Similarly, she has noted that reductions in cognitive disability occur in the absence of improvement on neuropsychological tests in patients involved in CR. These observations bring into question the selection of outcome measures used in studies of CR and warrant a reexamination of the field's goals for treatment (ie, disability reduction versus cognitive impairment reduction). Neuropsychological measures were not specifically designed to assess treatment changes in behavioral outcome. Hence, they may lack the necessary sensitivity to assess improvements in cognitive disability.
--Compensatory Approaches
Unlike the approaches reviewed above that attempt to enhance cognition, compensatory approaches place primary emphasis on bypassing cognitive impairments to improve broader aspects of function. Impairments in cognition are circumvented either by recruiting relatively intact cognitive processes or by utilizing environmental supports and adaptations to cue and sequence target behaviors. Two illustrative compensatory programs are described.--
Errorless learning is a training approach based on the theoretical belief that the commission of errors adversely affects learning in certain neurologically impaired groups. Two reports provide evidence that the commission of errors during learning is particularly problematic for persons with schizophrenia.50,51 In an errorless learning approach, the task to be trained is broken down into small component parts with the simplest tasks trained first, followed by more complex ones. During training, a wide variety of teaching methods and instructional aids are implemented to prevent errors from occurring. Each component skill is then overlearned through repetitive practice. In errorless learning 2 procedural principles are emphasized: (1) prevention of errors during learning and (2) automation of perfect task execution.--Kern et al.52 found that cognitive deficits were not related to vocational task performance in patients who were trained using errorless learning methods, but that cognitive deficits predicted performance in those trained by conventional means. This finding provides some evidence that errorless learning may in fact compensate for deficits in cognitive functioning in patients with schizophrenia. Kern et al. speculate that by utilizing this approach, the patient is not called upon to monitor mistakes and correct them. In addition, errorless learning may make use of implicit memory processes that may be relatively spared in schizophrenia patients in comparison to explicit memory processes. In a study of 65 clinically stable outpatients, Kern et al.53 found errorless learning to improve performance of entry-level job-training tasks relative to conventional training. Moreover, Kern et al.54 have extended the use of errorless learning to more complex tasks, such as social problem solving, with positive results.--
Cognitive Adaptation Training (CAT) is a compensatory approach using environmental supports and adaptations such as signs, checklists, medication containers with alarms, and the organization of belongings to prompt and sequence target behaviors such as taking medication and taking care of living quarters. Treatment strategies are based on a comprehensive assessment of cognitive functioning, behavior, and environment. CAT is based on the idea that impairments in executive functioning lead to problems in initiating and/or inhibiting appropriate behaviors. Using behavioral principles such as antecedent control, environments are set up to cue appropriate behaviors, discourage distraction, and maintain goal-directed activity. In addition, adaptations are customized for specific cognitive strengths or limitations in attention, memory, and fine motor control (eg, changing the color of signs frequently to capture attention, using Velcro instead of buttons for someone with fine motor problems). In 2 studies Velligan et al.55,56 randomized a total of 90 medicated individuals with schizophrenia to 1 of 3 treatment groups: (1) CAT, (2) a control condition involving home visits and environmental changes not related to functioning (eg, bedspreads), and (3) treatment as usual. Participants in CAT improved in severity of symptoms and level of adaptive functioning compared with the other treatments groups. Effect sizes for improvements in adaptive functioning were large (Cohen's d > 8.0).
Summary
In general, the results from the review of these cognition enhancing and compensatory approaches to CR are encouraging. Improvements in cognition have been found using different theoretical and conceptual approaches and using computer- and noncomputer-based methods. The findings are not uniformly positive, but one would not expect them to be so at this stage of CR development. Few approaches have more than 3 data-based studies supporting their efficacy in schizophrenia. With respect to broader outcomes, more data is needed, but there is evidence that participation in CR can lead to improvements in social and vocational functioning.--One issue that remains to be clarified concerns dosing—that is, how often and how long does a participant need to be involved in training to show meaningful gains. This appears particularly germane given the recent findings from Medalia's lab concerning the relationship between training intensity and training outcome. At present, there are no agreed upon guidelines for levels of intensity and duration of training.
--Looking Beyond Cognition: Motivation and Expectancies
The preceding review reflects a diverse and ever-growing movement aimed at addressing cognitive dysfunction in schizophrenia. Given the robust literature showing a relationship between neurocognition and functional outcome (see reviews2–4), most would argue that cognition is a worthwhile treatment target. However, despite its attractiveness, it is by no means obvious that the extent of disability that is prototypical of schizophrenia would be expected simply on the basis of the extent of cognitive impairment. That is, the functional disability of schizophrenia appears to be more severe than would be expected solely on the basis of general cognitive impairment on the order of 1–1.5 standard deviations below the normal mean (as revealed in the meta-analysis of Heinrichs and Zakzanis10). Clearly multiple factors contribute to this “excess” disability, including the burden of residual symptoms, the social stigma of mental illness, and illness onset disrupting the acquisition of the education, vocational skills, and normative experience needed to navigate the transition to adult independent role functioning, among others. Insofar as these “noncognitive” variables contribute to disability, it stands to reason that they will also likely limit the direct translation of gains in cognitive performance achieved through rehabilitative techniques into enhanced functional status. However, even after considering the contribution of the above social and symptomatic factors, it is our clinical view that the illness typically includes a compromise in motivation that is responsible for some of the “excess” disability and is therefore a critical treatment target.--Motivation can be defined as an internal state or condition that serves to activate or energize behavior and give it direction. Clinical observation of many patients suggests a profound lack of active, adaptive engagement with the environment. Although many patients possess certain cognitive skills and routines when assessed formally, these skills are often not brought to bear on events and challenges encountered in daily life. In essence, standard environmental cues do not appear to reliably activate the effort of patients, and many fail to adjust their performance in the face of changing contingencies. Similarly, the experience of success, and of failure, often does not lead to behavioral adaptation as one might expect in a non-ill group. Thus, the essential impairment in schizophrenia appears to be focused at the intersection of cognitive and motivational processes, where the consequences of actions serve to shape changes in behavior leading to more successful adaptation.--Recent basic neuroscience research has suggested that the dopamine system plays a critical role in precisely this type of ongoing behavioral activation and regulation.57 Two lines of research are particularly germane for the clinical phenomenology of schizophrenia and a consideration of rehabilitation. Based on a large body of animal research, Berridge and Robinson58 have argued that the dopamine system plays a critical role in the generation of reward-seeking behavior rather than of hedonic experience itself. That is, dopamine is involved in how much an animal “wants” a reward, not how much they “like” a reward, as shown in studies where the administration of dopamine-blocking drugs reduces the amount of effort/work that an animal will make to receive a reward but does not alter actual reward consumption. This conceptualization of the role of dopamine has been captured in the term “incentive salience,” suggesting that dopamine cell firing serves to increase the salience or desirability of a stimulus or action that is associated with a rewarding outcome. This notion is particularly relevant for schizophrenia, as a large body of research clearly demonstrates that patients experience surprisingly normal responses to a wide array of emotionally evocative stimuli.61–66 In essence, many patients with schizophrenia are not truly anhedonic: the observable muted emotional expressiveness and lack of goal-directed behavior cannot be attributed to an actual decrease in emotional experience or pleasure. Instead, it appears that many patients do not “want” the things that they “like.” The extent to which this is intrinsic to the illness versus an adverse outcome of treatment with dopamine-blocking drugs is a critical issue for future research.67–69 However, this basic science highlights an important clinical challenge: insofar as the “wanting” system is compromised in patients, it can be expected that positive outcomes and experiences achieved in rehabilitation settings will drive learning in a less than optimal or expected fashion. Indeed, it is possible to conceptualize the efficacy of behavioral treatment approaches through the use of the salience framework. One of the hallmarks of social learning and token economy approaches is that these interventions serve to highlight the “value” associated with various behaviors. This explicit and externally provided mapping of action outcomes may well compensate for a patient deficit in the ability to use internal representations to serve this function. The success of these approaches demonstrates that the reward system in schizophrenia is not completely shut down and unavailable; the system can be activated with vigorous external cueing.
The incentive salience line of pharmacological research is complemented by single cell recording studies of behaving nonhuman primates that have detailed the role of dopamine cell firing patterns in ongoing behavioral regulation and learning. Studies in behaving nonhuman primates have shown that phasic increases in dopamine cell firing occur when events are better than expected or predicted.57,70–72 Similarly, transient decreases in dopamine cell firing occur when events are worse than expected. These phasic increases and decreases in dopamine cell activity have been shown to correspond with those generated by temporal difference error learning algorithms widely used in the area of machine learning and computational modeling.57,73,74 In these models the error signal is used as a means of optimizing ongoing behavioral performance, and applied to behaving primates or humans, it is hypothesized that the dopamine error signal (DA) is broadcast to multiple striatal and frontal areas and serves to guide reinforcement learning and activate cognitive control. This reinforcement learning “system” is obviously relevant in the case of highly salient rewarding stimuli and experiences. However, several recent computational modeling and event-related potential studies have suggested that this same basic mechanism is involved in mediating human cognitive control, error monitoring, decision making, and managing the contents of working memory.75 McClure et al.76 have argued that the different emphases of temporal difference error models versus the salience model of Berridge and Robinson are more apparent than real and can be reconciled within a unified computational approach. In essence, this is a transactional system, where learning occurs in relationship to both external outcomes and expectancies, and which deals with extended sequences of behavior. If schizophrenia were to compromise the functioning of this system, the results would be profound (a notion addressed from a different perspective 35 years ago by Stein and Wise77). In essence, patients would have difficulty initiating behavior to pursue valued goals, leading to a failure to develop the competencies needed to achieve them. Further, they would fail to make behavioral adjustments in the face of negative outcomes.
If the functional disability of schizophrenia is caused, at least in part, by dysfunction within this cognitive/motivational system, this system may be a critical, explicit target for remediation efforts. CR interventions are often designed in an effort to attenuate the negative impact of motivational deficits on the task at hand—improving cognitive skill. For example, many approaches use high levels of positive social feedback or actual token reinforcers for on-task cognitive performance. Another design strategy includes manipulating expectancies for success. It will be important to identify which types of external manipulation of reinforcement contingencies best address the underlying systems' level of dysfunction.
One model, the NEAR program,34 has been designed with a specific focus on motivational issues, building on a large body of educational research that has emphasized the importance of intrinsic motivation. Intrinsic motivation occurs when task performance, in and of itself, is rewarding. Such tasks elicit high levels of engagement and active interest on the part of the learner. Indeed, there is a large, and somewhat controversial, literature that suggests that extrinsic rewards may actually serve to decrease intrinsic motivation, at least in specific task environments. Three aspects of the NEAR model are designed to enhance intrinsic motivation. First, the program utilizes educational software packages that are highly engaging. Thus, rather than the repetitive “drill and practice” of cognitive routines that is common to other computer software programs, the NEAR software is chosen to engage cognitive routines in a visually interesting, interactive context. Second, patients are encouraged to choose the programs and activities that are the focus of the rehabilitation sessions. Although the leader can be helpful in assisting the patient to make a selection, the patient is free to choose what he or she may like to do best, thereby increasing the role of intrinsic motivation. Further, the NEAR leader serves as more of a coach than a teacher; rather than teaching a specified curriculum, the leader provides prompts and tips that serve to help the patient get further along the path he or she has chosen. Thus, the overall clinical model is designed to enhance the motivational salience of the activities and the role of the patient as an independent agent in the rehabilitation process.
Available data to date suggest that the NEAR model does yield measurable significant cognitive benefits. These benefits are largest in the participants who were most actively engaged in the program as reviewed by Medalia and Richardson.38 Patients who completed the same number of sessions over a much longer period demonstrated much more modest cognitive benefits. Two hypotheses are suggested by these data. First, it is possible that the results simply reflect an effect of more “massed” rather than spaced practice. Alternatively, it is the activation of intrinsic motivational processes that serves to enhance the cognitive benefits of NEAR. While speculative, the latter idea can be seen as consistent with the role of dopamine in enhancing learning through the selective reinforcement of successful cognitive routines.
Other models of CR, though not designed around the issue of intrinsic motivation, address motivation in different ways. For example, in Cognitive Adaptation Training it is possible that the environmental supports that prompt and sequence appropriate behavior may bypass deficits in intrinsic motivation, as they tend to rely more on basic stimulus-response learning. All the models described herein provide a great deal of positive reinforcement for participation, including social support and praise. In addition, some offer money for time spent in remediation. The extent to which such externally mediated rewards serve to increase the level of intrinsic motivation that can persist after withdrawal of the treatment sessions is an important issue. That is, the question of interest may not be the persistence of trained cognitive/behavioral response repertoires but the likelihood that such responses are likely to be elicited on the basis of internal representations and goals. Silverstein and Wilkniss18 and Silverstein et al.78 have suggested that this process can be aided by making the goals of treatment more personal and making the process of therapy more goal-directed and understandable for the participant. Silverstein et al.78 describe a model of increasing the base rate of a desired behavior through extrinsic reinforcement, which then leads to a positive gain spiral of improved self-efficacy, intrinsic motivation to perform the behavior, and increased task engagement and performance. While evidence for simple durability of training effects is scant, the question of the persistence of motivational gains has not been investigated explicitly.
The issue of expectancies appears to be addressed to some extent by many of the models described herein. Standardized computer tasks allow for very precise alteration of the level of task difficulty based on an individual's performance. As performance improves, the difficulty of the task is increased, keeping expectations for success fairly constant and at a high level. Similarly, with errorless learning and environmental supports, the expectations for success are kept high. With errorless learning in particular, training is designed to minimize and if possible eliminate the occurrence of errors during the learning of new tasks and skills. These procedures function to bypass the need to make adaptive changes to environmental feedback (eg, developing an alternative response following a mistake). As noted above, there is reason to suspect that the usage of negative feedback may be an important area of deficit in schizophrenia linked to dysfunction of the dopamine system, where such error information is encoded as a transient cessation of dopamine cell firing. In addition, increasing patients' expectancy of success in the performance of these tasks may help motivate patients to continue task performance and develop competencies that he or she would be unable to develop in an unstructured environment with a higher probability of failure.
Though this discussion is speculative, it is clear that issues of motivation and expectancies have potentially important implications for conceptualizing the conduct and targets of CR. Targeting cognition alone may restrict the ability to see meaningful gains from rehabilitation efforts. For example, if the target of remediation is verbal memory, but a patient's functional disability is not in the capacity to remember information but in the ability to use memory in the pursuit of goals, enhancements in memory per se, while welcome, may be insufficient to produce clinically meaningful change in behavior. Second, the role of affective and motivational factors, particularly in how these intersect with cognitive processing, may need to be more deliberately addressed in CR interventions. These processes are briefly discussed in a recent review by Silverstein and Wilkniss.18 Simply providing salient stimuli (perhaps as in social, role-playing-type exercises) may be useful in the conduct of CR sessions, but it is unknown if this results in increased responsiveness to the salience of events outside of CR. We concur with the recommendation made by Barch 200579 that the field focus its energy on defining motivation and on the development and testing of assessments for use with patients with schizophrenia. Perhaps utilizing a measure of treatment engagement or working alliance would help to clarify the relationship between motivation to engage in CR and outcomes from cognitive rehabilitation. Third, if part of the essential deficit in the illness is a form of disengagement from the environment, the emphasis on a trainer-driven curriculum of exercises, as is typical of the field, is also open to question. That is, such approaches may not challenge the passivity that is characteristic of the illness, unless care is taken to engage the patient in a fully collaborative fashion. It is possible that the extent to which models are trainer-driven versus driven by the individual may be related to the variation in effect sizes between studies. Some evidence suggests that studies that adopt a more strategic approach to learning versus drill and practice seem to produce larger treatment effects.19,80 As should be clear, we are far more certain that motivational deficits are a critical part of the illness that need to be targeted by CR than we are confident that we know how to treat them at present. Current intervention approaches all acknowledge the importance of these problems in the conduct of CR. We suggest that the cognitive gains achieved through CR are likely to be consequential for functional outcome to the extent that these underlying motivational and self-regulatory mechanisms are altered in the context of CR.
Good luck.
 
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Does anyone knows about imaginal exposure and rescripting in Cognitive Behavoural Therapy?
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I am aware that you can use CBT to actively change your thoughts about memories.  However, I am interested in whether there are therapies to actively get rid of bad memories.  For example, when a person becomes stressed about a current activity, they may dream about previous bad experiences.  Is there a way to actively get rid of these memories so they no longer affect the person?
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Dual role- Therapist abiding by the spirit of MI at the same time being on a multi-disciplinary team that confrontation is used frequently to point out substance use.
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Hi John,
This is challenging because your program appears to use an AA disease model with confrontation as one of its main interventions, whereas MI is much more supportive and collaborative.
In response to your question, I have these ideas:
  • As long as your program permits the use of MI, you'd use confrontation with some clients when it's most appropriate, and use MI with others when it fits them.
  • In the best interest of some of your clients, you may integrate the two approaches in a sequential manner if necessary.  
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Anything to prove this!
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Interesting question, hope attached studies is sort of proof enough in related field.
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I studied the article entitled "Do we need to challenge thoughts in cognitive behavioral therapy?" by Richard J. Longmore and Michael Worrell. I'd like to read more about it.
Do you know any paper on interventions related to this?
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How about examining emotions for a change? I like what Stephen Craig Messer wrote - "For me learning, motivation, development, and evolution are my explanatory frames" - and I agree with him. Some of you might find the work of Bob Moss worth reading. Robert Moss PhD (he is on RG) - Clinical Biopsychology and Emotional Restructuring. What Bob writes rings true for me - and I will use this as my framework when trying to help clients. I do not have a particular fondness for CBT and all the "third wave" off-shoots. I like to keep it simple - when I am in doubt I think of Pavlov and the saliva flows! :-)
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It seems to me that research on heuristics and biases  from cognitive psychology could help CBT to understand more about the causes and the persistence of cognitive distorsions. However, I was able to find very few published works that try to integrate these two research traditions: https://www.researchgate.net/publication/247212928_Cognitive_factors_in_clinical_research_and_practice
Are you aware of some other similar works?
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For a different perspective on cognitive biases see for example:
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Does CBT reduce the risk of aggression in adult patients with deficits in anger management?
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yes!
check out the attached paper by shelley et al: cbt in a group setting was used to target all five dimensions of pathology revealed by factor analysis of the panss, including excitement (but, in a very similar factor analysis by marder et al. called hostility)
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I urgently need a program of latent inhibition in humans, I like that I could pay
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I'm not aware of any software however, you could program something like this via SuperLab software. In fact, one can program just about anything with SuperLab. Maybe try looking into that? Hope this helps. 
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I don't access to any english book and chapter in this area. thank you.
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Omid Saed,
Try this book A Transdiagnostic Approach to CBT using Method of Levels Therapy: Distinctive Features. Hope it helps
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I am wanting to generate a pre-test of death anxiety in subjects without using any mortality salience primer. My hypothesis is that people who fit DSM criteria for active substance abuse will score higher in DA at baseline even without death reminders. I am theorizing they have a particular lack of self-esteem buffers to MS and DA. The point is to test and see if baseline DA alone is sufficient to identify the substance abuser apart from the average temperate drinker. Thoughts? Method suggestions?
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Swedish guidelines from Socialstyrelsen favour CBT for mild, either CBT or SSRI for moderate depression and does not recommend a combinatory approach with integrated psychopharmacological and cognitive behavioural treatment.
Clinical case observations may indicate that CBT combined with SSRI can have beneficial effect, especially for relapse prevention.
What is the state of the art due to current research for adults 18 - 60 years of age?
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Dear Caro
This is an excellent question, but I think it might be hard to give a definitive answer. I wonder if there are any studies on the quality of the CBT that is provided. Skill level of a a CBT clinician might be relevant as regards the parts of your question that refer to superior to, good, vice versa. Best wishes Paul
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Does anyone know of empirical evidence demonstrating the observation that distraction can modulate both reappraisal and rumination (indirectly through reducing distress) in the context of emotion regulation? This relationship is suggested in Susan Nolen-Hoeksema's review on rumination entitled "Rethinking Rumination" (2008, p. 410). This relationship is stated via the diagram on page 410, however no direct citations are stated indicating the empirical support for this claim. Based on the way it is phrased however, it seems that this question was addressed in work by Susan Nolen-Hoeksema and her colleagues - however I am having trouble finding this empirical support.
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There is a recent opinion paper on this topic, which includes some updated citation you may find interesting:
Also there are a few imaging papers trying to compare distraction and other emotion regulation strategies:
Kanske, P. Heissler, J. Schönfelder, S. & Wessa, M. (2012). Neural correlates of emotion regulation deficits in remitted depression: The influence of regulation strategy, habitual regulation use, and emotional valence. Neuroimage, 61, 686-93.
Schönfelder, S., Kanske, P., Heissler, J. & Wessa, M. (2014). Time course of emotion-related responding during distraction and reappraisal. Social Cognitive and Affective Neuroscience, 9(9), 1310-1319.
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We are trying to set a goal for rate of follow-through for referrals from our behavioral medicine consultants, who are integrated in our primary care department (community outpatient) to on-going psychotherapy? Does anyone know of literature that suggests a baseline for how many patients that are referred for therapy actually follow through?
UPDATE 6/25: Note that the referral is actually to a different department. Patients would be getting referred from a primary care appointment in which they meet with a behavioral health consultant. The BH consultant will be referring the Pt. to on-going therapy with a different therapist altogether. What referral follow-through rate should we expect, based on the literature?
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I have a published study on this and I believe it is a similar format to what you are doing. I am a consultant within a primary care clinic where I receive referrals from PCPs. Most of these are a one time evaluation with referral to a behavioral health clinic for psychotherapy. About 85% of patients followed through with the referral from their PCP to me and of those I suggested to follow up with therapy, about 55% did. Here is the citation for the paper but feel free to contact me for a copy if needed:
Miller-Matero, L.R., Dubaybo, F., Ziadni, M., Feit, R., Kvamme, R., Eshelman, A., &Keimig, W. (2015). Embedding a psychologist into primary care increases access to behavioral health services. Journal of Primary Care and Community Health, 6, 100-104.
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I have been reading numerous journal articles on  the connection between cognitive behavioural therapy and depression.  Do suggest me any articles..
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Another related article: is attached
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Anxiety sensitivity is a temperamental factor in explaining of emotional disorders. it had been studied in many researches, but can high scores in tools of assessing this factor predict treatment output in CBT?
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Dear Omid, 
Cogn Behav Ther. 2006;35(4):248-56.
A brief cognitive-behavioral approach to reducing anxiety sensitivity decreases pain-related anxiety.
Watt MC, Stewart SH, Lefaivre MJ, Uman LS.
 
Abstract
Anxiety sensitivity (AS; fear of anxiety-related sensations) is a known risk factor for anxiety disorders and recently has been linked to pain disorders. The present study was guided by the hypothesis that a program designed to reduce AS levels might also result in a decrease in anxiety related to pain sensations. Female undergraduates, selected as either high or low in AS according to screening scores on the Anxiety Sensitivity Index (ASI), were randomly assigned to participate in 3 1-hour, small group sessions of either cognitive behavioral therapy (CBT; psycho-education, cognitive restructuring, and interoceptive exposure) or a non-specific treatment (NST). Immediately prior to and following the intervention, participants completed the 20-item Pain Anxiety Symptoms Scale (PASS-20). Consistent with hypothesis, results revealed a 3-way interaction between AS group, intervention condition, and time on PASS-20 total scores. Only participants with high pre-morbid levels of AS assigned to the CBT condition showed a significant reduction in scores on the PASS-20 from pre- to post-treatment. Implications for improving CBT approaches for pain disorders are discussed.
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How effective is CBT for autistic characteristics in epilepsy if the ability to self-reflect is impaired?
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With Kind Regards,
Thanks to everyone working in the field of Neurosciences, Neurogenesis and reserve for the welfare of mankind.
Autism and  Epilepsy- Differences >  Brain - Anatomy- Histology- Physiology, Pathology, Molecular- Genetics. Nutrition / Many causes.
Kind Regards, 
Mujeeb ur Rehman Sohoo,
Lecturer
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Procrastination is a transdiagnostic phenomena that is common in some psychopathology And it's prevalent in academic and health care setting. Can anyone help me to find manuals based on CBT to this problem?
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CCI from Autralia has a CBT manual for procastiantion.
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In anorexia nervosa (AN) treatment would bring the patient to stop controlling his food intake; but in Diabetes Mellitus food intake often have to be strictly controlled in order to maintain glycemia. Moreover, glycemia control could be used by AN patients to control their weight gains. How could we reconcilliate these two lines of treatment ?
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I treated two cases who suffered of anorexic symptoms and diabetes, one adult and one child. Both were females. I found it very difficult to cope with that symptomatologic co-presence, that obliged patients to focuse on body functioning. In the case of child diabetes offered a way to establish a better relationship with the mother, in the adult diabetes was a way to be in touch with the dead father.In both cases, the main difficulty was in joining the psychic reality, were the body was so preminent. Would you like to discuss about that? L
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Medication? Psychological therapy?
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Dear Ellen,
Thanks for your question. I appreciated the input from Joanne, Ariel, and Lewis. The following links to some treatment guidelines for adults with ADHD might be of interest to you.
Best,
Stephen
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I am looking for a treatment strategy to work with clients with co-occurring mental illness diagnoses.
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Thank you for clarification re: NICE recommendation
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Low self esteem is core in most psychopathology but there are rare guidelines, manuals, and protocols to help therapists to cover this condition.
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Hi Miriam
LSE isn't disorder based on any classification, but It is transdiagnostic phenomena that can be share in many disordres such as dysthymia. In CBT approach, there are protocols that focus this part of psychopathology particularly.
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Are there randomized controlled trial studies on Effectiveness of Online CBT for Anxiety Disorders, Obsessive-Compulsive Disorders, and Pathological Gambling?
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I refer you to an excellent review by Newman et al. (2011) about this very issue (minimal-contact treatments for depression and anxiety):
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I conduct trauma focused cognitive behavioral therapy will children. I have begun including play therapy in my sessions.  I have not been able to find sufficient research studies on play therapy and trauma. 
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Hello Nathalie Mac-Guffie,
 
I have not conducted any research or a similar research of this kind, especially with children. I have been working with some elderly with cognitive behavioural impairment, where  I have seen play and humour enabling some access to reach out to them, especially when communicating with them became very challenging.
You can take a look at the links attached here which I believe would serve a great purpose bringing you to a desired goal.
 
Developmental Play Therapy in the Treatment of Childhood Trauma
 
4 Treatment Options for Children with Post-Traumatic Stress Disorder
 
Attachment and Trauma Treatment Centre for Healing (ATTCH)
 
The Use of Play Therapy for Children Who Have Experienced Emotional and Physical Trauma Worldwide
I hope you find these information useful. Good luck.
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I am a MSc year 2 student studying Mindfulness studies and a Psychological therapist/counsellor working with clients one to one using mindfulness.
I am interested in what influences a therapist in the decision to introduce mindfulness or not.  What is  it about client characteristics or perceived receptiveness that makes the therapist introduce or not. 
I am if i get enough input or find enough articles to support this investigation going to study it in year 3 a my work base project so would really appreciate your help in offerring your thoughts. 
Kindest Regards
Vivienne Robertson 
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Depending on what the presenting issues are, mindfulness techniques may be incorporated even within pure cognitive-behavioural treatments. A number of sources now (e.g., Hoffman et al., 2008) point to the importance of cognitive flexibility. That is, the ability to use different adaptive emotion regulation strategies (acceptance being one of them) depending on the situation and one's emotional reaction. So, reappraisal strategies (pure CBT) may not be appropriate in all situations, and so cultivating flexibility in the use of various emotion regulation strategies may be ideal.
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Many secondary source texts do not address the evolution of Alfred Adler's theory; that is, his movement from psychoanalysis to his later (1920 - 37) theory and practice ideas that integrate cognitive, constructivist, existential-humanistic, systemic, and psychodynamic perspectives. Much of contemporary psychology, psychotherapy, and counseling is replete with Adler's ideas although they use different nomenclature and almost never mention Alfred Adler.  Albert Ellis stated that "Adler, perhaps more than Freud, is true father of modern psychotherapy."  The existential psychiatrist, Henri Ellenberger, said that no author's work has been used more and acknowledged less than Alfred Adler.  The theory textbooks by Corey and Prochaska and Norcross echo the statements by Ellis and Ellenberger.
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Hello, Richard and Béatrice. To answer the question baldly is "No," and I confess that I had not picked up subsequently on Adler's evolution. My excuse is that I hail from the Rogerian camp. Having gotten that out of the way, I am greatly intrigued by several aspects of your conversation. Neither in order nor exclusively: (1) The study and appreciation of the growth and development of the ideas of any great thinker is always enlightening. (2) The notion of power, rather than pleasure, being fundamental to the psychology of neurosis rings true if one considers human evolution (the archaeology of neurosis and the theoretical reconstruction of human development, as it were). (3) Which leaves me in a position. The link to Durbin 2004 <http://www.encyclopedia.com/doc/1G1-128445468.html> goes to an Oops page, regrettably.  I am left, as an unwashed and unlearned undergraduate, seeking bibliographical signposts. Where do you suggest I begin?
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As many of you know, we (psychotherapy researchers) have often focused on symptoms measures as measures of outcome. My students and I are trying to develop a more comprehensive measure that will include items about coherence, freedom to choose to mention just a few aspects of this new measure that have not always been included in past studies. My question is what aspects of psychotherapy outcome do you think a comprehensive (but short) measure of therapeutic outcome should include besides symptoms? The most helpful answers will be phrased very clearly and not include jargon. Thanks
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What I hear from my patients is not that their symptoms or problems disappear but that their functioning has improved. That they can do more, listen more to their family, do things at home, go out for shopping, eventually start working again, et cetera. Most of them still have the same fears, nightmares, bad sleep, which appear in the symptom check lists, but when asked they say they feel better because they can do more.
My suggestion would be to include a general functioning list, although it stays important to listen to their own opinion about it.
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I'm interested at comparing the two programs for a few children I work with in ABA sessions. I wondered if anyone has seen or done a study comparing the two or would like to consider doing aiding a study on this?
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up
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I am experimenting with a self help group for male-batterers based on the 12-step program of Alcoholics Anonymous. I am looking for literature on the subject and i am interested in experiences of other therapists/ researchers working with self- help groups for men who have difficulties in controlling their anger.
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See this group doing with violent men in Australia - http://ntv.org.au/ No To Violence, Male Family Violence Prevention Association website.
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Papers on Early responders to CBT for children and adolescents with OCD or Anxiety
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