Paradigm clashes and progress: a personal reflection on a 50-year association with ABCT

Why is ABCT a successful, vibrant, and growing association when most other professional associations are withering on the vine? Since the first annual meeting of the organization, which I was privileged to attend, I have witnessed repeated changes in direction as new paradigms were introduced and debated. The clashing of ideas in these debates in our Association over the years centered on such things as classical versus operant learning principles, cognitive versus behavioral modes of intervention, the introduction of a focus on modifying affect and emotion, and “third wave” approaches. Indeed the very founding of the organization was based on a fundamental paradigm clash with the prevailing psychoanalytic approaches in the 1960s. The fact that through it all the organization continues to thrive reflects the secret to our success and our fundamental strength, a reliance on the slow but inexorable process of science.Accepted manuscrip

Anger: the unrecognized emotion in emotional disorders

Anger plays a prominent definitional role in some psychological disorders currently widely scattered across DSM‐5 categories (e.g., intermittent explosive disorder, borderline personality disorder). But the presence and consequences of anger in the emotional disorders (e.g., anxiety disorders, depressive disorders) remain sparsely examined. In this review, we examine the presence of anger in the emotional disorders and find that anger is elevated across these disorders and, when it is present, is associated with negative consequences, including greater symptom severity and worse treatment response. Based on this evidence, anger appears to be an important and understudied emotion in the development, maintenance, and treatment of emotional disorders.First author draf

Addressing neuroticism in psychological treatment

Neuroticism has long been associated with psychopathology and there is increasing evidence that this trait represents a shared vulnerability responsible for the development and maintenance of a range of common mental disorders. Given that neuroticism may be more malleable than previously thought, targeting this trait in treatment, rather than its specific manifestations (e.g., anxiety, mood, and personality disorders), may represent a more efficient and cost-effective approach to psychological treatment. The goals of the current manuscript are to (a) review the role of neuroticism in the development of common mental disorders, (b) describe the evidence of its malleability, and (c) review interventions that have been explicitly developed to target this trait in treatment. Implications for shifting the focus of psychological treatment to underlying vulnerabilities, such as neuroticism, rather than on the manifest symptoms of mental health conditions, are also discussed.First author draf

Modified brinley plots: advantages and disadvantages

Accepted manuscrip

A functional analysis of two transdiagnostic, emotion-focused interventions on nonsuicidal self-injury

OBJECTIVE: Nonsuicidal self-injury (NSSI) is prevalent and associated with clinically significant consequences. Developing time-efficient and cost-effective interventions for NSSI has proven difficult given that the critical components for NSSI treatment remain largely unknown. The aim of this study was to examine the specific effects of mindful emotion awareness training and cognitive reappraisal, 2 transdiagnostic treatment strategies that purportedly address the functional processes thought to maintain self-injurious behavior, on NSSI urges and acts. METHOD: Using a counterbalanced, combined series (multiple baseline and data-driven phase change) aggregated single-case experimental design, the unique and combined impact of these 2 4-week interventions was evaluated among 10 diagnostically heterogeneous self-injuring adults. Ecological momentary assessment was used to provide daily ratings of NSSI urges and acts during all study phases. RESULTS: Eight of 10 participants demonstrated clinically meaningful reductions in NSSI; 6 participants responded to 1 intervention alone, whereas 2 participants responded after the addition of the alternative intervention. Group analyses indicated statistically significant overall effects of study phase on NSSI, with fewer NSSI urges and acts occurring after the interventions were introduced. The interventions were also associated with moderate to large reductions in self-reported levels of anxiety and depression, and large improvements in mindful emotion awareness and cognitive reappraisal skills. CONCLUSIONS: Findings suggest that brief mindful emotion awareness and cognitive reappraisal interventions can lead to reductions in NSSI urges and acts. Transdiagnostic, emotion-focused therapeutic strategies delivered in time-limited formats may serve as practical yet powerful treatment approaches, especially for lower-risk self-injuring individuals.Dr. Barlow receives royalties from Oxford University Press, Guilford Publications Inc., Cengage Learning, and Pearson Publishing. Grant monies for various projects come from the National Institute of Mental Health (F31MH100761), the National Institute of Alcohol and Alcohol Abuse, and Colciencias (Government of Columbia Initiative for Science, Technology, and Health Innovation). Consulting and honoraria during the past several years have come from the Agency for Healthcare Research and Quality, the Foundation for Informed Medical Decision Making, the Department of Defense, the Renfrew Center, the Chinese University of Hong Kong, Universidad Catolica de Santa Maria (Arequipa, Peru), New Zealand Psychological Association, Hebrew University of Jerusalem, Mayo Clinic, and various American Universities. (F31MH100761 - National Institute of Mental Health; National Institute of Alcohol and Alcohol Abuse; Colciencias (Government of Columbia Initiative for Science, Technology, and Health Innovation))Accepted manuscrip

Why Can't We Be More Idiographic in Our Research?

Most psychological scientists make inferences about the relations among variables of interest by comparing aggregated data from groups of individuals. Although this method is unarguably a useful one that will continue to yield scientific advances, important limitations exist regarding the efficiency and flexibility of such designs, as well as with the generality of obtained results. Idiographic research strategies, which focus on the intensive study of individual organisms over time, offer a proficient and flexible alternative to group comparison designs; however, they are rarely taught in graduate training programs and are seldom used by psychological scientists. We highlight some of the unique strengths of idiographic methods, such as single case experimental designs, and suggest that psychological science will progress most efficiently with an increased use of such methods in both laboratory and clinical settings.Psycholog

Cognitive-behavioral therapy for anxiety in Parkinson's disease

Parkinson's disease (PD) is characterized by motor symptoms, but nonmotor symptoms also significantly impair daily functioning and reduce quality of life. Anxiety is prevalent and debilitating in PD, but remains understudied and undertreated. Much affective research in PD focuses on depression rather than anxiety, and as such, there are no evidence-based treatments for anxiety in this population. Cognitive-behavioral therapy (CBT) has shown promise for treating depression in PD and may be efficacious for anxiety. This exploratory study implemented a multiple-baseline single-case experimental design to evaluate the utility and feasibility of CBT for individuals with PD who also met criteria for a DSM-5 anxiety disorder ( n = 9). Participants were randomized to a 2-, 4-, or 6-week baseline phase, followed by 12 CBT sessions, and two post treatment assessments (immediately post treatment and 6-week follow-up). Multiple outcome measures of anxiety and depression were administered weekly during baseline and intervention. Weekly CBT sessions were conducted in-person ( n = 5) or via secure videoconferencing ( n = 4). At post treatment, seven of the nine participants showed significant reductions in anxiety and/or depression, with changes functionally related to treatment and most improvements maintained at 6-week follow-up. Effects of CBT on secondary outcomes varied across participants, with preliminary evidence for reduction in fear of falling. Adherence and retention were high, as were treatment satisfaction and acceptability. The findings of this pilot study provide preliminary evidence for the utility of CBT as a feasible treatment for anxiety and comorbid depressive symptoms in PD and highlight the potential of telehealth interventions for mood in this population.Accepted manuscrip

Expectancies, working alliance, and outcome in transdiagnostic and single diagnosis treatment for anxiety disorders: an investigation of mediation

Patients’ outcome expectancies and the working alliance are two psychotherapy process variables that researchers have found to be associated with treatment outcome, irrespective of treatment approach and problem area. Despite this, little is known about the mechanisms accounting for this association, and whether contextual factors (e.g., psychotherapy type) impact the strength of these relationships. The primary aim of this study was to examine whether patient-rated working alliance quality mediates the relationship between outcome expectancies and pre- to post-treatment change in anxiety symptoms using data from a recent randomized clinical trial comparing a transdiagnostic treatment (the Unified Protocol [UP]; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Client workbook, Oxford University Press, New York, 2011a; Barlow et al., Unified protocol for transdiagnostic treatment of emotional disorders: Patient workbook. New York: Oxford University Press, 2017b) to single diagnosis protocols (SDPs) for patients with a principal heterogeneous anxiety disorder (n = 179). The second aim was to explore whether cognitive-behavioral treatment condition (UP vs. SDP) moderated this indirect relationship. Results from mediation and moderated mediation models indicated that, when collapsing across the two treatment conditions, the relationship between expectancies and outcome was partially mediated by the working alliance [B = 0.037, SE = 0.05, 95% CI (.005, 0.096)]. Interestingly, within-condition analyses showed that this conditional indirect effect was only present for SDP patients, whereas in the UP condition, working alliance did not account for the association between expectancies and outcome. These findings suggest that outcome expectancies and working alliance quality may interact to influence treatment outcomes, and that the nature and strength of the relationships among these constructs may differ as a function of the specific cognitive-behavioral treatment approach utilized.This study was funded by grant R01 MH090053 from the National Institutes of Health. (R01 MH090053 - National Institutes of Health)First author draf

Experiential avoidance as a mechanism of change across cognitive-behavioral therapy in a sample of participants with heterogeneous anxiety disorders

Despite the substantial evidence that supports the efficacy of cognitive-behavioral therapy for the treatment of anxiety and related disorders, our understanding of mechanisms of change throughout treatment remains limited. The goal of the current study was to examine changes in experiential avoidance across treatment in a sample of participants (N = 179) with heterogeneous anxiety disorders receiving various cognitive-behavioral therapy protocols. Univariate latent growth curve models were conducted to examine change in experiential avoidance across treatment, followed by parallel process latent growth curve models to examine the relationship between change in experiential avoidance and change in anxiety symptoms. Finally, bivariate latent difference score models were conducted to examine the temporal precedence of change in experiential avoidance and change in anxiety. Results indicated that there were significant reductions in experiential avoidance across cognitive-behavioral treatment, and that change in experiential avoidance was significantly associated with change in anxiety. Results from the latent difference score models indicated that change in experiential avoidance preceded and predicted subsequent changes in anxiety, whereas change in anxiety did not precede and predict subsequent changes in experiential avoidance. Taken together, these results provide additional support for reductions in experiential avoidance as a transdiagnostic mechanism in cognitive-behavioral therapy.First author draf

Development of an integrated cognitive behavioral therapy for anxiety and opioid use disorder: Study protocol and methods

Opioid use disorder is a highly disabling psychiatric disorder, and is associated with both significant functional disruption and risk for negative health outcomes such as infectious disease and fatal overdose. Even among those who receive evidence-based pharmacotherapy for opioid use disorder, many drop out of treatment or relapse, highlighting the importance of novel treatment strategies for this population. Over 60% of those with opioid use disorder also meet diagnostic criteria for an anxiety disorder; however, efficacious treatments for this common co-occurrence have not be established. This manuscript describes the rationale and methods for a behavioral treatment development study designed to develop and test an integrated cognitive-behavioral therapy for those with co-occurring opioid use disorder and anxiety disorders. The aims of the study are (1) to develop and pilot test a new manualized cognitive behavioral therapy for co-occurring opioid use disorder and anxiety disorders, (2) to test the efficacy of this treatment relative to an active comparison treatment that targets opioid use disorder alone, and (3) to investigate the role of stress reactivity in both prognosis and recovery from opioid use disorder and anxiety disorders. Our overarching aim is to investigate whether this new treatment improves both anxiety and opioid use disorder outcomes relative to standard treatment. Identifying optimal treatment strategies for this population are needed to improve outcomes among those with this highly disabling and life-threatening disorder.This study was funded by NIDA grant DA035297. The funding source had no involvement in the study design, analysis and interpretation of data, writing of the report, or the decision to submit the article for publication. (DA035297 - NIDA)Accepted manuscrip