Final

Question 1

What are psychodynamic therapies?

Answer 1

• Originate from Psychoanalysis
• The name has changed because they don’t have that analysis part as much
• They’re shorter -> only usually happen 1x/week and not for years on end
• Many of these therapies are short-term (similar to courses of CBT)
• Focus on unconscious processes that impact client’s present behaviour (how they differ from CBT)
• Ex: with CBT, we’re focused on what people are thinking and we have to be able to access those thoughts, whereas with psychodynamic therapies, we’re trying to pull out these unconscious processes through various techniques (ex: dream analysis)

Question 2

What are some examples of psychodynamic therapies?

Answer 2

• Short-term psychodynamic therapy (can be used broadly)
• Mentalization-based therapy
• Developer: Peter Fonagy
• Treatment used for BPD that focuses on trying to get people to understand better their own emotions as well as the emotions of others
• Transference-focused psychotherapy
• Also a treatment for BPD and other personality disorders
• Focuses on the client-therapist relationship and uses these transference processes to improve people’s relationships with others in their lives

Question 3

What are humanistic/experiential therapies?

Answer 3

• Interpersonal types of therapies
• Originate from Rogers and client-centered therapy
• Based on premise that individuals are “self-actualizing” -> they want to be the best versions of themselves

Question 4

What are some examples of humanistic/experiential therapies?

Answer 4

• Gestalt therapy
• Existential therapy
• Emotion-focused therapy
• Other: Interpersonal psychotherapy

Question 5

Describe Interpersonal psychotherapy

Answer 5

• Developed in the 70s as a controlled condition for studying pharmacotherapy for the treatment of depression
• It was meant to be just a supportive psychotherapy control condition
• They found that it was equally as effective as pharmacotherapy
• People have been interested in it as an alternative to CBT and it shows pretty good efficacy for things like depression and BN and binge eating disorder where interpersonal events often trigger negative affect which then triggers binge eating
• It’s seen as an evidence-based alternative but more of a 2nd line treatment if CBT isn’t a good option

Question 6

According to Blagys & Hilsenroth (2000), what distinguishes psychodynamic and humanistic/experiential therapies from CBT?

Answer 6

1. A focus on affect and the expression of patient emotions
   - Although CBT is focused on emotions as to be able to identify your automatic thoughts, one of the first things you need to be able to do is to tune into when you’re having an emotional response and for some clients this is more difficult for them than others (so there’s more time spent on this)
   - BUT, the cognitive restructuring/change is what CBT is focused on whereas the others have more focus on emotions (especially emotion-focused therapy)
   - Intellectual/cognitive insight not sufficient, need emotional insight or to believe what we’re saying or changing and not just walk/talk through the motions
   - Encourage expression of emotions (especially in a safe environment -> ex: in a therapy context) rather than management or
   control (not bottle up emotions -> a lot of 2nd conflict comes from bottling up emotions)
   - Draw attention to feelings patient regards as uncomfortable -> people don’t like to talk about their emotions and often don’t like to have emotions, even in therapy, but we’re trying to activate them to experience that
2. An exploration of the patient’s attempts to avoid topics or engage in activities that hinder therapy progress
   - Interpreting client’s behaviour that may suggest they’re resistant to therapy or there was a particularly tough session and then they missed the next session
   - Ex: redirecting conversation when tough topic comes up, not completing homework, missing sessions, not paying bills
   - Explore these disturbances to uncover unconscious meaning -> common in these types of therapies to have conversations about this therapy process and to see if there’s any unconscious meaning and if the client is trying to say something that they don’t necessarily have the words for
   - May make more of that in a psychodynamic or interpersonal therapy compared to CBT
3. Identification of patterns in patient’s actions, thoughts, feelings, experiences, relationships
   - Identify patterns beyond those in thoughts -> interested in more than just thoughts but rather patterns across the board
   - How patterns in interpersonal functioning repeat over time, settings, and people (ex: talking about how people’s interpersonal styles can repeat overtime and in various types of relationships and can mirror early childhood relationships that are being repeated later, they can interact with the therapist in similar ways as other people in their lives)
   - Patterns are identified through interpretations (the therapist suggests to the client some type of pattern that they’ve observed and see if it rings true for the client and see what type of reaction the client has -> ex: if the client is defensive about it or open to it)
4. An emphasis on past experiences
   - Identify origin of patient difficulties and understand why/how they have manifested in lifetime (both past and present)
   - Emphasize both pre-adult (childhood experiences) and adult past
   - Recent trend for PI treatment to be more present-focused (needs to be focused on the present and to incorporate the past to whatever extent is possible)
   - For therapies to be short-term, it’s hard to focus on the past because therapy is about working on maintaining processes and these are not necessarily the same things that initially led to the development of the disorder or even past iterations of the disorder
5. A focus on patients’ interpersonal experiences
   - Understanding problematic relationships -> why do people find themselves in problematic relationships and what type of need is this fulfilling
   - Problematic relationships interfere with ability to fulfill needs and wishes
   - Compare and contrast patient functioning with that of others -> understanding how the person functions relative to other people
   - Impact patient has on other people -> especially important for clients with personality disorders that might have trouble seeing how their behaviour is impacting other people
6. An emphasis on the therapeutic relationship
   - Therapeutic relationship is a vehicle or medium of change
   - If therapist is able to maintain boundaries and get the client to work within the confounds of this relationship then this can translate into other relationships in their life
   - Transference = patient’s projections onto therapist -> this can be identified, interpreted and discussed within the therapy
   - Therapist elicits feedback about client’s reactions to therapy -> always asking clients how they’re reacting to the therapy and how they feel opening up to another person if that’s something that’s been difficult for them in the past (CBT also does this)
7. An exploration of patients’ wishes, dreams, or fantasies to some extent
   - Could be clues to unconscious functioning
   - The basis of psychoanalysis
   - This is seen less these days but definitely not something you would see in CBT

Question 7

Describe Short-Term Psychodynamic Therapy

Answer 7

Goal:
- Symptom relief (most people present to therapy because they’re having some distressing or impairing symptoms) and limited, but significant, character change
- Idea with long term psychodynamic/psychoanalytic therapy where you’re trying to make more personality and interpersonal changes that take a long time to make and take a lot of practice to have new patterns of behaviour
- Less of this that can happen in a short-term treatment but there’s hope that a lot of what’s being discussed will be generalized and will lead to some of this character change
- Work on one circumscribed area of focus (whether it’s presenting symptoms or an interpersonal problem)
Structure:
- Once per week for less than one year (ex: 16 sessions) -> but oftentimes when it’s studied in the context of research, especially if it’s being compared to CBT, you want it to be the same length (ex: 16 sessions)
- Therapist must maintain therapeutic eye on chosen focus -> the therapist is responsible and helps guide the client to maintain the focus on whatever area was chosen as the area of focus because with limited time, if you get too far off track, there’s going to be less progress that can be made during that time
Candidature:
- Patients should be psychologically minded, insightful, motivated (these would be great qualities for anyone presenting to therapy but it’s not always the case)
- Not going to make a whole lot of change if the person isn’t ready and if the person isn’t able to stay on task in such a short time
- Capacity to engage in the focal area readily and disengage from other distracting areas easily

Question 8

Why is behaviour change so hard for people?

Answer 8

We’re so used to and stuck to our routines that it’s hard to form new routines

Question 9

Describe the techniques of Short-Term Psychodynamic Therapy

Answer 9

Supportive:
- Defining the therapeutic “frame” (the boundaries around therapy, the fact that the therapist is not your friend and they have a very particular role and are not going to have personal convos about what you’re doing on the weekend and things like that -> tradition of psychoanalytic and psychodynamic therapy)
- Demonstrating genuine interest and respect for the client (common factor types of skills)
- Noting gains (helps people to feel like they’re making progress, they feel self-efficacy, they’re further motivated to make more progress, important in any type of treatment but particularly a short-term treatment where you’re trying to get people to move forward quickly)
- Maintaining here-and-now perspective
Expressive:
- Offering empathic comments
- Confrontation (when needed - questioning people if they’re not attuned to how they might be influencing other people or how there might be patterns in their relationships, more just questioning)
- Interpretation (suggesting things based on what the client has said -> ex: patterns of relationships in terms of impact of the past on present functioning, not drawing conclusions)
Monitoring countertransference:
- To see how you might be reacting to the client
- This can slow therapy down if the therapist is having some negative feelings towards the client and are therefore not being as effective in their sessions, can take away from the potential for progress

Question 10

Describe Steinert et al. (2017) study on the efficacy of short-term psychodynamic psychotherapy

Answer 10

• This article uses a traditional RCT framework to test whether there’s evidence for superiority of CBT or alternative treatments (most of them were CBT)
• Meta-analysis of 23 RCTs comparing psychodynamic therapy to an established treatment (all RCTs that were not waitlist control or were not compared to a supportive psychotherapy), both treatments using manuals (amenable to a research design)
• Article doesn’t explicitly talk about it being short-term, but the trials ensured that there was comparability across the session lengths
• There were short-term forms of psychodynamic treatment
• Primary outcome: target symptoms (ex: depression)
• Secondary outcome: general psychiatric symptoms and psychosocial functioning
• The way that they set up the goal of the study was to test for the equivalence of the 2 treatments -> they were looking that the 2 things would not be significantly different from one another
• Found that there were no meaningful differences and statistical differences between the psychodynamic and the comparator treatments at post-treatment (g = -0.15) and follow-up (g = -0.05)
• At post-treatment, the negative effect size means that there was a slight favouring for the CBT but the effect size magnitude is very small -> suggests there’s no meaningful difference
• Difference favouring psychodynamic treatment for psychosocial functioning at follow-up (g = 0.16) -> consistent with the proponents of psychodynamic therapy (could argue that there was some potential benefit to general functioning with this option for treatment)
• Statistical difference but still very small effect size
• There are differences in terms of main disorders that you’re approaching and the way that it’s being done
• Not all short-term psychodynamic therapies are equivalent but there’s some evidence for their use and consideration

Question 11

Describe the choice for the primary and secondary outcomes in Steinert et al. (2017) study on the efficacy of short-term psychodynamic psychotherapy

Answer 11

• Oftentimes what happens is that you might see a difference on target symptoms but not general psychosocial functioning
• People who are proponents of psychodynamic treatment will argue that ultimately we care more about functioning but will still want to put these head-to-head and see how they compare to the outcomes that are typically studied in CBT (symptom functioning)
• Ex: depressive symptoms in the context of people with depression

Question 12

What are the limitations to psychodynamic treatment that explain how people conclude that CBT is way more efficacious than psychodynamic treatment?

Answer 12

• Psychodynamic treatment doesn’t always lend itself as well to manuals or to short versions of the treatment
• Sometimes the goals are different
• The goal of CBT is often symptom change whereas the goal of psychodynamic therapy is often broader character change which takes longer

Question 13

Describe Emotion-Focused Therapy

Answer 13

• Developed by Leslie Greenberg at York University
• Originally called Process-Experiential therapy
• Typically a short-term treatment (16-20 sessions)
• The theoretical basis is that emotion is a key determinant of self-organization
• At some point in our lives we’re told that emotions are bad, harmful and inconvenient and need to be suppressed
• But emotions are useful from an evolutionary standpoint (they tell us about when we need to act and when we need to retreat, or who we should maintain contact with vs not), but how we make sense of our emotional experiences is influenced by culture and early upbringing
• We want to re-learn how to make sense of our emotions in the treatment
• Has a lot of benefits for certain clients
• The therapy distinguishes between primary emotions and secondary emotions

Question 14

What are the different types of emotions?

Answer 14

• Primary: direct initial reaction (ex: sadness from loss) -> instinctual emotion
• Secondary: secondary to primary emotions (happen after - ex: guilt/shame over sadness) -> our judgment of our emotions
• Ex: the loss happened a while ago and you’re still sad but you feel guilty for that because you feel like you should’ve gotten over it already
• Adaptive: primary emotions that communicate info (ex: evolutionary basis of the fight-or-flight response and how we use emotions to navigate our environment)
• Maladaptive: “old familiar feelings” that don’t change with situation
• Ex: things that we may have been stuck with for a long time since childhood that don’t change based on the situation -> not communicating info in the same way

Question 15

What are the 3 principles targeted in treatment in Emotion-Focused Therapy?

Answer 15

1) Emotion awareness
- Want to be aware and learn to know how we’re feeling in a particular moment (very hard for people)
- Become aware of primary adaptive emotions
- Not thinking about feeling, but actually feeling the emotion -> trying to take the cognitive part out of it, do a lot of tough work in sessions to get patients to arouse those emotional experiences and have them actually feel them rather than just talk about or around them, which is often what happens
- Accept rather than avoid emotional experiences
- Express emotions, including what you feel in words and talking about how it feels in the body and what the emotions make you want to do (behavioural urges or tendencies associated with emotions)
2) Emotion regulation
- First, work to determine which emotions need to be regulated (a lot of primary emotions, depending on the situation, don’t necessarily need to be regulated -> ex: if the person’s having a lot of anger and it’s leading to a lot of anger outbursts in inappropriate situations (ex: the workplace) then this might be different)
- We want to look at the adaptive vs maladaptive view on the emotions
- Teach emotion regulation skills, including tolerance for a certain level of emotion and self-soothing when we need to (ex: children cuddling with their favourite stuffed animal or going to their parents or deep breathing and other skills to manage the strong types of emotions)
3) Emotion transformation
- Process of changing emotion with emotion (undo a maladaptive emotional response with a more adaptive emotion)
- Ex: “Fight fire (emotion) with fire (emotion)”
- Different from CBT because with CBT we would say we want to think about the situation differently and if we think about it differently then our emotional responses differ VS here we’re throwing a different emotion on top of it
- Techniques used in emotion transformation: shifting attention from the negative to the positive aspects of a situation (ex: looking on the bright side), positive imagery, remembering another emotion (ex: you’re feeling sad and you think about times where you have felt happy)

Question 16

What are some other techniques used in Emotion-Focused Therapy?

Answer 16

1) 2-chair dialogue for self-critical conflicts
- A person who’s trying to gain confidence in themselves but are often criticizing themselves and are having trouble merging those 2 parts of themselves can play out both sides of the conversation
- Similar to CBT technique of “what would you tell a friend in this situation?”
- Trying to externalize or look at yourself from an outsider’s perspective to be able to hear the kinds of things that you’re saying to yourself in your head and notice how mean they may be
- Other part would be to respond to it, to manage some of those conflicts
2) Empty-chair work for unfinished business
- You have an empty chair in the room and the person is talking to it
- Ex: for someone in your life who has passed away or has become estranged and you want to get out some of those “old familiar feelings” that are keeping you stuck by sharing some of those thoughts

Question 17

Describe the research evidence for EFT for major depression

Answer 17

• EFT has primarily been studied for major depression
• The research evidence is a bit old
• Watson et al. (2004):
• Outcomes similar in EFT and CBT
• Greater decrease in interpersonal problems in EFT compared to CBT (makes sense based on the focus of the therapy)
• Other people have commented that EFT is just like a supportive therapy and that there isn’t much substance to it
• Goldberg et al. (2006):
• Compared EFT to client-centric therapy
• Symptom remission greater in EFT compared to client-centered therapy
• The focus on emotions does matter and it’s doing more than just that supportive nature that a client-centered therapy would provide

Question 18

Describe Interpersonal Psychotherapy

Answer 18

• Developed by Klerman and Weissman in 1970s
• Concerned with interpersonal context
• Relational factors that predispose (vulnerability factors -> earlier things), precipitate (factors that come right before the onset of the disorder), and perpetuate (maintenance factors that continue it going) distress
• Structure: 12-16 sessions
• Suitability: in an ideal world, clients who pursue this treatment would have a secure attachment style (wouldn’t have a lot of trouble with attachment), they would have a specific interpersonal focus of distress, and have a good support system to help them navigate difficult conversations
• Ex: a couple with interpersonal problems -> wouldn’t be a good idea to do this with an abusive spouse or someone who’s emotionally neglectful
• Developed as a control treatment

Question 19

Describe the potential problem areas explored in Interpersonal Psychotherapy

Answer 19

• Role transitions (positive or negative stressful life events -> ex: moving, new job, getting married, getting divorced)
• Role disputes (within the context of a particular relationship -> ex: infidelity, unmet expectations)
• Grief (could be used for a loss)
• Interpersonal sensitivity (general pattern that characterizes people often since early in their life where they have difficulty forming and maintaining relationships)
  -> What’s generally recommended is to only focus on the interpersonal sensitivity area if there’s not another topic that could be the focus
  -> Because it’s a general pattern that people have had for a while, it’s going to be harder to change and you’re most likely going to get less out of the treatment
  -> This is sort of a last resort type of focus

Question 20

Describe the structure of Interpersonal Psychotherapy

Answer 20

• Early-on, during the assessment phase, there’s an interpersonal inventory that’s administered to assess different life experiences and that’s used to choose the problem area
• Work collaboratively with the client to develop solutions to problem
• Patient implements solutions (activities and exercises) between sessions

Question 21

Describe the techniques found in Interpersonal Psychotherapy

Answer 21

• Interpersonal incidents: something happened (ex: a fight occurs with a partner or family member) and we’re going to be detailing those incidents to understand what happened -> similar pattern is communication analysis
• Communication analysis: ineffective communication is thought, according to this therapy, to underlie the problems that people are experiencing and we’re going to figure out exactly what happened and what could’ve been done differently -> where problem-solving would come in
• Problem solving and role-playing (ex: if there’s a big thing coming up, you need to talk to your boss about a raise or have a difficult convo with your mother, then you can roleplay this conversation with your therapist to practice it)
• Encouragement of affect: in terms of the content of what’s happening in the person’s life and in the therapy session but also the process of being able to talk about these things that are generally quite difficult for people

Question 22

Describe the video example of the communication analysis technique in Interpersonal Psychotherapy

Answer 22

• Therapist offers to go through arguments in conflict in more detail
• Therapist asks client if there’s anything that they could have done differently in this conflict with other person
• Therapist brainstorming with client the other ways she could have acted/done to avoid conflict
• Therapist asks how client reacted to the other person’s arguments and then what they answered and then what the client answered (to see how the situation escalated)
• They’re going through each step of this interpersonal interaction (trying to figure out what did the client say, what could they have done differently, how did it make them feel each step)
• Analyzing this incident/pattern of communication

Question 23

Describe the research evidence for Interpersonal Psychotherapy

Answer 23

• Quite a well-studied psychotherapy
• Depression:
• Cuijpers et al. (2016)
• Meta-analysis of 62 RCTs of IPT for depression
• d = .62 in favour of IPT compared to control treatments
• d = .06 for IPT compared to other psychotherapies
• Found that it out-performed control treatments and doesn’t differ from other psychotherapies
• Bulimia nervosa (BN) and binge eating disorder (BED):
• Agras et al., (2000): CBT more rapidly improves BN symptoms, compared to IPT, but those treated with IPT continue to improve post-treatment
• They found that it takes longer for clients to get to the same point -> they’re slower to improve in interpersonal psychotherapy, compared to CBT, but when they actually finish the therapy, they continue to improve
• When they assess people at follow-up, they find new differences between CBT and IPT
• This suggests that clients are learning skills to improve their interpersonal relationships and improve their communication with other people, that they continue to practice when the therapy is over that continues to help them
• There’s also group formats of IPT that have been comparable to group CBT
• Wilfley et al., (2000): Group IPT comparable to group CBT for BED

Question 24

What’s mindfulness according to Jon Kabat-Zinn?

Answer 24

“The awareness that arises from paying attention on purpose, in the present moment, and non-judgmentally” (1994)

Question 25

Who is often considered to be the person that brought mindfulness to the western world?

Answer 25

Jon Kabat-Zinn

Question 26

What are the 3 components of mindfulness?

Answer 26

• Attention: fully attending to the present moment without being preoccupied with the past or the future
• Intention: knowing why we’re doing what we’re doing -> “on purpose” part of the definition
• Attitude: the way in which we pay attention
• Ex: we stay kind, curious, open, and non-judgmental

Question 27

What are Kabat-Zinn’s 7 attitudinal foundations of mindfulness?

Answer 27

• Non-judging (being an impartial witness to your own experience -> seeing the experience from an outsider’s perspective)
• Patience (letting things unfold in their own time without trying to rush the experience)
• Beginners mind (always having a beginners mind even if you are very far into your mindfulness journey or practice, being receptive to new things or possibilities that mindfulness might bring you)
• Trust (trusting yourself, your feelings, your experience, the process)
• Non-striving (not trying to achieve anything, not trying to move anything forward, only goal is to be yourself and where you’re at and not trying to change anything)
• Acceptance (seeing things as they are in the present moment)
• Letting go/be or non-attachment (ex: when you’re falling asleep, the act of letting yourself go and fall into sleep -> having this same experience when you’re awake and practicing mindfulness)

Question 28

Describe formal mindfulness meditation practice

Answer 28

• Set aside a time and have a particular spot in which you do this
• This includes:
• Mindful breathing (paying attention to your breath, counting your breath, making sure to breathe in/out for a certain amount of time)
• Body scan (paying attention to different areas of your body to notice them and notice if you have any sensations of pain or relaxation)
• Mountain meditation (picturing yourself as a mountain and being at a particular spot (the mountain is and always will be), there may be weather around the mountain (emotions and sensations that change) but the mountain is always there steady and still)
• Loving kindness meditation (developing or trying to foster warm and kind thoughts for yourself and other people in your life, including people that you may not get along with)

Question 29

Describe informal mindfulness meditation practice

Answer 29

• Awareness of thoughts, emotions, bodily sensations and sensory input during everyday activities (ex: walking, washing dishes, brushing teeth, eating)
• Taking the time to actually feel the sensations of these things and being present for these activities
• Incorporating it into your daily routine
• Mindful eating is recommended in terms of paying attention to your hunger and satiety and the taste and smell of the food

Question 30

Describe Mindfulness-Based Stress Reduction (MBSR)

Answer 30

• Formal program developed by Kabat-Zinn
• Mindfulness packaged into a program -> not a psychotherapy but a formal program
• 8-week workshop with 2-3 hour group sessions each
  week, daily homework, and one-day retreat
• Not considered a formal therapy, but a compliment to traditional medical (treatment for physical illness) or psychological treatment
• Designed to try and reduce stress and maybe work on burn-out -> terms that are not necessarily formal psychological conditions
• Quite commercialized
• To be a certified MSBR teacher, you have to complete a 7-day course at Center for Mindfulness at U Mass Medical Center which is specifically offered by Kabat-Zinn center
• People have to go through this process and it’s not cheap in terms of being a program

Question 31

Describe Mindfulness-Based Cognitive Therapy (MBCT)

Answer 31

• Mindfulness has also been incorporated into other types of existing psychotherapy
• Developed in late 90s for depression relapse prevention (at this time, it wasn’t recommended as a first line treatment for people experiencing current depression, this would be cognitive therapy or CBT, but for people who are vulnerable to multiple episodes of depression, this would be a way to potentially increase the time that they may have without an episode of depression)
• Group treatment that integrates MBSR with CBT
• Group-based treatment that integrates learning skills and the inclusion of homework practice of mindfulness with some CBT skills
• Move away from CBT’s emphasis on changing content of negative thinking towards attending to way in which all experience is processed
• We see this in 3rd wave behavioural therapies like mindfulness, ACT and DBT because what they’re trying to do is move away from actually changing our thoughts and changing the content of our thoughts, towards attending to the way in which our experiences are processed and whether that’s thoughts, emotions, bodily sensations, just being aware and noticing them

Question 32

Describe Teasdale et al. (2000) study on Mindfulness-Based Cognitive Therapy (MBCT)

Answer 32

• One of the early trials where everyone was in a CBT treatment for depression and then at the end of that treatment, they were either randomized to treatment as usual (if they really relapsed and needed more treatment they would go back to treatment, but most were without treatment) VS the mindfulness-based cognitive therapy
• A much lower percentage of people relapsed in the treatment condition (MBCT)

Question 33

Describe the evidence for efficacy for MBSR and MBCT

Answer 33

• Hoffman et al. (2010):
• Mindfulness-based therapy for depression and anxiety across a range of conditions (physical and mental)
• Pre-post treatment: g = 0.63 for anxiety and g = 0.59 for mood -> moderate-to-large pre-post treatment effects
• In patients with mood and anxiety disorders, g = .97 for anxiety and g = .95 for mood -> large effect sizes
• Khoury et al. (2015):
• Studied MBSR in healthy individuals
• Pre-post mindfulness: g = 0.55 -> medium effect sizes
• Between-group: g = 0.53
• Found large effects on stress, moderate effects on depression, anxiety, distress, quality of life
• Evidence that these approaches are helpful for people, regardless of whether they have a psychological problem
• We all experience stress and have times of anxiety and low mood and these things can be helpful in terms of changing our relationship with our emotional experiences and our thoughts

Question 34

What’s the one thing that mindfulness has been looked at a lot for?

Answer 34

• Physical complaints (ex: pain) because pain is an experience that people can react very negatively to which can increase their experience of pain
• If you learn to recognize your pain without reacting negatively to it, it may not have this paradoxical effect

Question 35

Describe Acceptance and Commitment Therapy (ACT)

Answer 35

• Developed by Hayes and colleagues
• Definition: “Therapeutic approach that uses acceptance and mindfulness processes, and commitment and behavior change processes, to produce greater psychological flexibility” Hayes, Wilson, Strohasal (1999)
• Traditional perspective on suffering: Humans are naturally psychologically healthy and, if we experience psychological pain of some sorts (ex: negative emotions, negative thoughts, bad interpersonal events), it means something is wrong and needs to be fixed (medical/biomedical perspective)
• We experience this anxiety or stress and we think something’s wrong and we have to change our environment or change the way we think, we have to do something to change
• ACT perspective on suffering: negative emotions and thoughts are normal human experience and suffering is due to use of language and our attempts to control our internal human experience
• Everyone of us has these and deals with these things, they’re not specific to people with depression or anxiety disorders
• The pain is normal but the suffering comes from our use of language and our attempts to control, change, or get rid of those negative feelings
• ACT doesn’t position itself as a treatment for any particular psychological condition or disorder
• It works on psychological flexibility
• ACT is meant to work on different processes that they think will enhance psychological flexibility

Question 36

What’s psychological flexibility?

Answer 36

Being able to relate to the world in a more flexible way and in a way where you’re more open to your experiences

Question 37

Describe the Philosophical Foundations of ACT

Answer 37

• Major criticism of ACT: it’s a little confusing and hard to follow
• But there’s a lot of good to it too
• Hayes was a cognitive developmental psychologist and worked with children in the early part of his career
• He wasn’t a clinical psychologist
• The development of ACT came from philosophical kinds of ideas as well as his research and empirical observations of children and the way that they learn language
• He developed Relational Frame Theory
• ACT is based on Relational Frame Theory (RFT)

Question 38

Describe Relational Frame Theory

Answer 38

• The way we navigate our world is based on what we’ve already learned about the world
• Our mind makes arbitrary connections between things, with connections based on history and context
• Ex: we might hear the world apple, we might see the picture of an apple in our head, we might think “apples taste yummy”, and we might also think apples are good to eat because they’re healthy
• We can make all of these connections just based on the fact that someone said the word “apple” and this is all based on our previous experience of knowing that most apples are red, having remembered times when we’ve eaten them before
• Ex: then we might hear the world melon, we might see the picture of a melon in our head and see how it’s bigger than an apple (comparing), and we then might think “melons are good but are not as good as an apple”
• Now, the way that they’re interpreting melons is based on the fact that they were just thinking about an apple
• Whereas if they weren’t thinking about an apple beforehand, they probably wouldn’t be comparing a melon to an apple in these other ways
• We make sense of our world based on our past experiences, based on the context we’re in and what we’re already thinking about, and we also make sense of our emotions and our thoughts in that same way
• We put weight on our emotions and our thoughts that they may differ and may not be as important depending on the context that we’re in (they’re just words)
• Ex: melon and apple are just words and it’s only on the fact that we have experience with them that we see them as actual objects
• But they’re just labels for objects
• Hayes would say that most of our suffering is due to our use of language

Question 39

According to Hayes, most of our suffering is due to what?

Answer 39

Hayes would say that most of our suffering is due to our use of language

Question 40

Describe the ACT Model of Psychopathology and Treatment

Answer 40

• Called a hexaflex
• There are 2: psychological inflexibility (hexaflex for what keeps us struggling/suffering) and psychological flexibility (the hexaflex we want to move towards in treatment)
• We want to move from psychological inflexibility towards psychological flexibility
• Each corner of the hexaflex has the problem and its opposite functional state (ex: from experiential avoidance to acceptance of our experiences)

Question 41

Describe the different components of the 2 hexaflexes of ACT

Answer 41

1) Cognitive fusion/Defusion
- Cognitive fusion: being fused with our thoughts
- “Verbal dominance over behavioural regulation” or taking your thoughts too literally
- Thinking that your thoughts are reality or experiencing yourself as your thoughts as opposed to looking at thoughts as what they are (just thoughts)
- Defusion: mindfully noticing thinking as it occurs
- Ex: In sessions of ACT, you would use terms like “I am having the thought that…”, rather than “I am worthless” or “I am incompetent”
- Want to focus on mentality of “I am having the thought that I am this” which doesn’t mean that you are this, it’s just the way that your brain is thinking
- Another technique would be to picture yourself sitting at the edge of a river and to watch your thoughts go by as if they were on leaves floating down a stream
- You can say “this is the thought, that’s not me, it doesn’t mean that it’s true”
- You’re passively watching the thoughts go by
2) Experiential avoidance/Acceptance
- Attempt to alter form, frequency, or function of our experience of our private events (ex: emotions, thoughts) even when doing so is costly or ineffective
- Trying to just push out and change and not have/suppress those negative emotions
- Need to move towards acceptance
- Acceptance: adopt an intentionally open and flexible posture about moment-to-moment experiences
- Being curious about them and observing them without judging them (using mindfulness kinds of skills)
- If we can just accept our experiences, then they don’t have as much control over us
3) Loss of flexible contact with the present (AKA dominance of the conceptualized past and forced future; weak self-knowledge)/contact with the present moment
- Fusion and experiential avoidance lead us to desire to be somewhere else
- We want to be in the past when things were better, we want to be in the future when something exciting is going to happen but we don’t want to be where we are right now with our current thoughts and emotions
- We want to work towards mindfulness and being in the present moment
- Attend to what is present in a focused, intentional, voluntary, and flexible way
- Use language to note and describe internal events and to understand current situation, rather than to predict what’s going to happen in the future and judge what’s happening right now
- Want to use language to describe in an observational and non-judgemental way
4) Attachment to the Conceptualized Self/Self as Context
- Conceptualized self: idea of ourselves that we hold (maybe it’s a past self or a self that was projected onto us by our parents or by society)
- We’re attached to this self that may not actually represent who we are
- Want to promote contact with sense of self based on the here-and-now -> sense of self right now (who we are right now)
- Using techniques such as “noticing self” and using an “observer perspective” (coming outside of ourselves and seeing ourselves in an objective way where we’re not so attached)
5) Values Problems (AKA Lack of Values Clarity; Dominance of Pliance and Avoidant Thinking)/Values
- Commitment and behaviour change part of the hexaflex
- Persist or change in behaviour in the service of one’s chosen values
- We want to make sure that we’re acting in ways that are consistent with the values that we hold for ourselves
- Either we continue towards things that are consistent with our values or we stop and we change directions if we’re acting in ways that aren’t consistent
- Values: Predominant reinforcer is intrinsic to behaviour pattern itself; a direction rather than a destination
- Key problems in values: they are not yours (they’re someone else’s values), they are not clear, they are based on avoidance (you’re trying to prevent something negative from happening rather than trying to move in a positive direction)
6) Inaction, impulsivity, and avoidance persistence/Committed Action
- Common behavioural patterns
- Inaction: common in depression
- Impulsivity: common in substance-use or binge-eating
- Avoidance persistence: anxiety disorders and avoiding the feared stimuli
- Instead of these types of patterns, which most likely aren’t going to be consistent with values, developing patterns of action that are linked to chosen values and working on goal-setting that are consistent with your values
- Set short-term, medium-term, and long-term concrete goals that are value-consistent
- Once you clarify your values, it’s easier to set goals based on those values

Question 42

Describe how values are different from goals

Answer 42

• Values: things that are important to us, but they’re not things that we’re going to say we achieved
• Ongoing thing throughout our life
• We’re going to have a certain set of values that sort of guide our behaviour and our choices
• Can never be done with these (as opposed to with goals) -> direction rather than a destination

Question 43

Describe ACT in Practice

Answer 43

• The psychoeducation section of ACT is very different in that we’re not educating people about a particular disorder or a particular maintenance process of a disorder -> it’s much more broad than that
• Due to problems with the nature of language, metaphors are used to explain ACT concepts to patients
• The use of metaphors is done a lot in ACT because according to ACT there’s this problem in language where we’re always making these associations which is going to be very idiosyncratic to the person based on their past experience or what they’re going through right now and so a lot of metaphors are used to get people to experience the idea as opposed to just talking about it
• One of the main things that you talk about with ACT early-on is the idea of creative hopelessness: bring people into experiential contact with the fact that what they have done so far has not worked
• They’ve been trying and have been very creative in their ways of trying to get rid of their suffering but it’s just creating even more hopelessness because everything they keep trying isn’t working

Question 44

Describe the 2 metaphors used for creative hopelessness in ACT

Answer 44

1) Chinese finger trap
- Game where you put your fingers in and the more and more you struggle to get your fingers out of this trap, the more it tightens and the more they get trapped
- The more that you struggle, the more suffering you actually have
2) Tug-o-war
- Person is having tug-o-war with all of their negative thoughts and feelings, their baggage and their past experiences and they’re each pulling as hard as possible and both of them are stuck
- Putting all of this energy but staying stuck
- We encourage people in ACT to put down the rope, stop the tug-o-war, stop trying so hard
- If you put down the rope, there’s no war anymore
- Idea that you can have these negative thoughts and baggage walk around with you and still do what you need to do and still get a lot out of life even with this in the background

Question 45

Describe the evidence for ACT

Answer 45

• ACT is not developed for a particular condition so it hasn’t only been studied in one area
• Quite a bit of research supporting it in terms of treatment
• Less good quality RCT evidence compared to other treatments
• Research support for treating: depression (would be easy to see based on creative hopelessness metaphors), mixed anxiety conditions, OCD (where people are very fused with their thoughts), chronic pain, psychosis
• Research focused on testing processes of change and on functional, rather than symptom-focused, outcomes
• A lot of the research instead of using a traditional RCT design, has tried to test the processes of change
• It’s trying to make sure that, similar to the Dimijian article on behavioural activation where they had 2 potential processes of change and set up a mediation model to test them, what these studies often do is they have ACT in the comparison and want to see if ACT changes these processes that are part of the hexaflex (ex: psychological inflexibility, experiential avoidance) more than comparison treatments and do changes in these processes then predict outcomes
• ACT research is more focused on functional outcomes as opposed to symptom-based outcomes
• Not tied to a particular set of symptoms and instead wants people to live a more rich, full, and value-based life and not let their emotions and thoughts bring them down and keep them stuck
• Mediation analyses that examine whether the treatment predicts change in ACT processes, which then predict change in outcome

Question 46

Describe Dialectical Behavior Therapy (DBT)

Answer 46

• The treatment was developed by Marsha Linehan who after developing the treatment has come out and talked about her own experience with suicidality and BPD
• Designed as a treatment for individuals with chronic suicidality or parasuicidality who did not respond favourably to standard treatments like CBT or other treatments
• People often think of DBT as a treatment for BPD
• Most patients with chronic suicidal behaviour have BPD, but not all patients with BPD have suicidal behaviour
• They still may be recommended to receive treatment with DBT
• Originally the development of this treatment was for the subset of people generally with a diagnosis of BPD that also had chronic suicidality or parasuicidality as one of their presenting features
• Recognition that many patients with this presentation can engage in behaviours that interfere with therapy, and that clinicians experience burnout and negative reactions to these patients
• Ex: suicidality -> not necessarily that this is interfering but this is very challenging for clinicians to deal with, they’re very concerned about clients who present with suicidal thinking and their main job is to keep their clients safe
• It’s important to evaluate the extent to which they think the client is at eminent risk
• Recognized that this treatment needed to include some support for the therapists to help boost their capacity to work with patients who were presenting with chronic suicidality
• Based on Linehan’s Biosocial theory of borderline personality disorder and her biosocial model of the development of the disorder

Question 47

What’s parasuicidality?

Answer 47

Including cutting behaviours without necessarily having a suicidal intent

Question 48

Describe Linehan’s biosocial model of the development of BPD

Answer 48

• Emotionally Vulnerable Person + An Invalidating Environment = Problems with 1) ability to understand & label feelings (to figure out what you’re feeling in a particular moment), 2) coping skills (ability to cope with stressful situations), 3) emotion modulation (ability to modulate your emotions appropriately)
• The model posits that it takes the trait characteristics of a person (vulnerability -> the person is more emotionally vulnerable, they have stronger emotional reactions and more quick reactions and have trouble coming down from those reactions) and if you put someone who’s emotionally vulnerable into an environment where their emotional reactions are invalidated (ex: they’re told why are you crying, why are you having this problem, there’s nothing to cry about, don’t feel that way) this combination is not good
• This can lead to problems with emotional skills
• Unfortunately, a lot of these emotional tendencies are partly genetically transmitted
• Parents that are emotionally vulnerable, often have children that are emotionally vulnerable and the child’s emotional vulnerability can activate the parents and then the parent responds in this invalidating way
• The child is getting both the genetic transmission and the environmental transmission of this emotional vulnerability
• Parents working on their parenting skills around emotions, especially if they’re prone to emotional vulnerability, can be a preventative mechanism for these later problems

Question 49

Describe the Dialectical Dilemma for the patient

Answer 49

• Emotional vulnerability (feeling like you really need someone to pay attention to the pain that you’re in and recognize how hard it is for you) vs self-invalidation (going back to what patients experienced as children and telling themselves that there’s no reason they should feel this way and that this is not a valid reaction and questioning why they’re so emotional and why they react like this)
• Active passivity (approaching life in a helpless way, not able to do things for yourself, need others’ help) vs apparent competence (other times patients can appear very competent and are able to pull themselves together but this is quite inconsistent)
• Unrelenting crisis (there’s always something going on that puts the person into crisis mode) vs inhibited grieving (when something real and stressful happens to the person, they have trouble letting themselves feel the stress or negative emotions)
• Patients go back and forth between these 2 patterns

Question 50

Describe the Dialectical Dilemma for the therapist

Answer 50

• Accept client as they are, but encourage change (basis of DBT)
• Ex: this is what your past and current experiences are, but how can we make small changes that might improve upon that
• Centered and firm (maintaining the boundaries of DBT), but flexible when needed
• Nurturing (empathic - lots of good common factors skills), but benevolently demanding (always pushing the client beyond where they think they can go)

Question 51

What’s the basis of DBT?

Answer 51

Accept client as they are, but encourage change

Question 52

What does dialectic stand for?

Answer 52

• Means there’s a balance
• Ex: 2 sides to a coin, there’s 2 sides to everything

Question 53

Describe the common ways of representing the Dialectical Dilemma and Therapist Stance

Answer 53

1) Often seen with a balance
- Balance between change/problem solving and acceptance/validation
- Not going to be perfectly balanced in every session
- But you overall want this balance so that the clients know that you’re there for them and that you’ll be there for them even if they struggle in this journey to change
2) Another way this presents is in a Venn diagram
- Contains the Rational Mind on one side and the Emotional Mind on the other and then the Wise Mind in the intersection of both
- Idea that we have our rational mind and our emotional mind
- Rational mind: past experience, logic, research, statistics, problem-solving
- Emotional mind: feelings, anxiety, anger, fear, stress, sadness
- Wise mind: “I feel this & I know this”, “So I will do this”
- “Wise mind is that part of each person that can know and experience truth. It is where the person knows something to be true or valid. It’s almost always quiet. It has a certain peace. It is where the person knows something in a centred way.”- Linehan
- It’s not that we don’t want to pay attention to that emotional mind, this is part of what leads to some of these issues (ex: bottling up emotions)
- But what we need to do is to balance these 2 parts into our wise mind and not to necessarily just be jumping between emotional and rational but really try to get to that middle point as your baseline
- Mindfulness is one technique to enhance wise mind

Question 54

Describe the DBT Treatment Package

Answer 54

• Weekly individual therapy sessions (look different from other types of therapies)
• Weekly group skills training session (multiple people and this is where you’re working on specific skills -> there’s a group of 4 skills that you work on in these sessions)
• Telephone contact (includes something unique given the types of presenting problems - this is the idea that in the midst of a crisis, before the person engages in suicidal or parasuicidal behaviours, they are encouraged to contact their therapist by telephone and work to de-escalate and put into practice some of the skills that they’ve learned)
• Therapist consultation team meeting (a way to support the therapist - meeting where they can get feedback working with particular clients and feel supported in their work)
• Client must commit to all parts of treatment package for at least 1 year (longer term treatment - these clients often receive multiple courses of treatment and so we want to give them a focused experience that hopefully will help even though it’s a long commitment)

Question 55

Describe the 5 Functions of DBT

Answer 55

1) Enhancing capabilities of the client
- Improve several life skills in the context of weekly skills
group session
- Aims to teach them skills to use to help manage emotions, to help increase mindfulness, to help with interpersonal problems
2) Generalizing capabilities beyond the therapy session
- Homework assignments to practice skills in natural
environment
3) Improving motivation for change and reducing dysfunctional behaviours
- Primarily accomplished in individual therapy
- Individual therapy is set up in a way that’s very behavioural in nature in terms of the contingencies that are put around what can be discussed in individual therapy
4) Enhancing and maintaining therapist capabilities and motivation
- Therapist consultation meetings provide support, validation, skill-building, and feedback
5) Structuring the environment to try and maximize the chances that the client is going to be able to implement the treatment
- One way that this is done is with the phone consultation -> if the client calls the therapist after having already engaged in a self-harm behaviour, the therapist is not to engage with the client because that reinforces the behaviour and not them reaching out to the therapist before engaging in the behaviour to try and do something else
- Strict rules about setting up the contingencies
- Want to reinforce effective behaviour/progress and not
reinforce maladaptive or problematic behaviour
- Patients also need to modify their own environment -> there’s often things in the person’s environment (people, places or patterns) that reinforce some of the behaviours so it’s important for them to take stock about how to make changes to set them up for success

Question 56

What’s the hierarchy of therapy targets in DBT Individual Therapy?

Answer 56

1) Suicidal and parasuicidal behaviours
2) Therapy interfering behaviours (including missing a session, leaving the prior session in a huff, potentially not completing homework)
3) Behaviours that interfere with quality of life (typically includes substance-use, eating disorder behaviours, things that lead to the person being unsafe in some way)
4) Behaviours related to post-traumatic stress
5) Improve self-esteem
6) Individual targets negotiated with client
- If one of these things has happened in the past week, this ends up being at least the initial focus of the therapy session
- A lot of what’s done in the individual therapy isn’t necessarily what the clients are bringing to sessions, which is different at least part of the CBT sessions would be focused on client-initiated topics
- The idea is that if clients know that this is the structure of treatment, they’re not going to be able to talk about their own things that they want to talk about if they engage in these behaviours that interfere with life or therapy
- This is then likely to decrease their use of those behaviours to manage their emotions
- At the same time, they’re learning skills to be able to decrease these behaviours
- The hope is that the contingencies will lead to fewer of these types of things

Question 57

Describe the video by Marsha Linehan on the hierarchy of therapy targets in DBT Individual Therapy

Answer 57

• She states that it’s important that therapists don’t set the goals of therapy, but clients do
• States that her job is to help clients achieve their goals and not to figure out what goals a client should have
• Once she knows what her goals are, it’s her responsibility to help them get there
• Argues that if you don’t know how to get them there, then don’t treat them because that’s what therapists are supposed to know how to do
• Therapists need to know what their clients want
• Argues that there are no goals from clients in which cutting and suicide behaviours will help them achieve said goals
• Have to get clients to agree not to kill themselves because then therapy won’t work (may be for the next 2 hours or the next week)
• “Therapy doesn’t work with dead people”
• She doesn’t ask clients to agree to never kill themselves, she asks whether they would like a therapy that would help them build a life where they didn’t want to kill themselves and whether this would be a reasonable goal
• States that the average client wants that
• Clients don’t ask for help to build a life where they won’t kill themselves because she argues that they don’t believe that there could be a life where they wouldn’t want to kill themselves
• This is part of why we have to work in this order, to be able to build that life by decreasing those behaviours and progressively working on the things that clients want to work on

Question 58

Describe the diary card

Answer 58

• Used in DBT Individual Therapy
• Self-monitoring for DBT
• The way of tracking behaviours that happened over the past week
• Track behaviours such as self-harm, suicide attempts,
  emotional misery
• Used to prioritize session time
• Ex: a diary card in terms of the urge to engage in self-harm
• Urges are different than behaviours but a helpful thing that can be done is to acknowledge an urge to engage in self-harm and then ask:
• Did you engage in self-harm?
• What did you do otherwise/instead of that?
• This is where we can see whether the skills are being put into place

Question 59

Describe Skills Training in DBT

Answer 59

• Includes 4 sets of skills:
  1) Mindfulness Skills
• Always the thing to start with because it gives people something to turn to in difficult times
• Considered to be a good solid base for the additional skills
• What skills (what does mindfulness entail): observe, describe (describe our experience -> sometimes we talk about describing the 5 senses), participate (in everyday experiences in a mindful way)
• How skills (how do we do this): Non-judgmentally, one-mindfully (with one-mind/wise mind), effectively
  2) Interpersonal Effectiveness Skills
• Important
• A lot of people with these presenting problems can have trouble in their relationships given their emotional vulnerability
• Idea is that in any interpersonal interaction, there’s 2 people involved and each person has an objective or a stance and you’re trying to balance the objective
  Ex: you want go to your boss and ask for a raise -> you have this objective of what you would like to accomplish, but it’s not just the objective that you pay attention to, you also have to pay attention to the relationship (probably an ongoing relationship), and your self-respect (your ability to push when necessary and to say no if someone’s asking you for something that you don’t want to give them)
• Objectiveness, Relationship, and Self-respect effectiveness
• Being able to balance these 3 components of an interpersonal interaction
  3) Emotion Regulation Skills
• Similar to other treatments
• Identify and describe emotions
• Important to be able to figure out how to respond to our emotions
• Need to know what they are and what would be an appropriate response
• Riding the wave of emotions (idea that emotions are temporary and increase just like a wave and there’s also a decrease and we have to just wait them out sometimes)
• Acting opposite to your emotions
• Ex: behavioural activation -> the person is depressed, they want to stay in bed, but we’re telling them to go do something to act opposite of the way that they’re feeling and this may actually be effective at changing the emotion
  4) Distress Tolerance Skills
• Sometimes hard to differentiate distress tolerance from emotion regulation
• Distress tolerance: times when your distress is so high that it doesn’t make sense to try and figure out what emotion you’re experiencing and you’re probably not going to be in a good place to be able to do cognitive restructuring, you just need to get through that moment
• Includes distraction, self-soothing (whatever it is that makes people feel better -> ex: kids with stuffed animal), radical acceptance (times when the distress is really high and you have to go use mindfulness and acceptance skills)

Question 60

Describe the Marsha Linehan video on Emotion Regulation Skills in DBT Skills Training

Answer 60

• BPD is primarily a pervasive disorder of emotions
• It’s the inability to regulate emotions
• Not only how you feel but also the physiology of emotions, the experience of emotions and the actions associated with emotions
• Patients with BPD have intense emotional suffering and are simultaneously unable to change their suffering and regulate the behaviour that comes from that suffering
• Teaching emotion regulation
• Linehan developed strategies for regulating emotions that have been taken from the science of emotions and from the evidence-based treatments that treat emotions
• Based on what therapists tell that client to do and Linehan repackaged all of this as a scale
• Argues that 1/2 of her patients if you ask them how they feel and what their emotion is, they’re functioning as if they’re looking at a fog -> they have no idea what their emotion is
• We have to teach them how to identify their emotions and how to regulate them
• Many strategies for regulation:
  1) Can look at the vulnerability factors
• Often you’re very emotional today because of something that happened the day before (ex: lack of sleep, poor nutrition)
• Look at what factors make you vulnerable to being emotional and how you can change those factors
  2) Can look at prompting event
• What happened right before
• Is this something that you can change and if you can this would lead to teaching problem-solving
• If you can’t change it this would lead to interpretation
  3) Can look at client’s interpretation
• Use of scale called “check the facts”
• How do you check the facts to see if your interpretations are correct
• There are a lot of different sub-scales in emotion regulation and we know that these scales are effective -> they’re effective in teaching people how to regulate emotions
• This is similar to biosocial model
• Idea is that emotion regulation or emotion regulation problems are core to BPD so there’s a lot of attention paid to these skills
• She also talked about using CBT types of skills, such as cognitive restructuring (“check the facts”), which is consistent with the idea that this is a 3rd wave treatment that combines the mindfulness piece with the more cognitive and emotional piece

Question 61

Describe Linehan et al. (2006) study on DBT

Answer 61

• Big and important study
• This study was impressive in terms of the way it was set up
• Dismantling study to examine specific ingredients of DBT that were important
• DBT is a treatment package that includes 4 different components
• Wanted to know which of these components is the most important
• In terms of investigator allegiance and bias, a lot of the research on DBT has been done by Linehan and her colleagues -> problem
• Control for DBT non-specific factors such as hours of therapy, availability of group consultation, etc.
• DBT is an intensive and year-long treatment, you have individual and group-based therapy, you have group consultation for the therapist
• There are all of these additional things that make it hard to compare it to something like a once weekly CBT without any of those additional things
• Participants were women with BPD with recent suicidal behaviour (attempt or self-injury) -> this is really what the treatment is aimed for
• Patients were matched to treatment condition on 5 prognostic variables -> they tried to do matching for baseline characteristics
• The comparison was an interesting treatment
• Community therapists were nominated based on expertise treating difficult/challenging clients, often clients with a BPD diagnosis, that were engaging in some kind of therapy that was non-behavioural or psychodynamic, to minimize the overlap with the DBT treatment
• It wouldn’t include things like cognitive restructuring or structuring the environment

Question 62

Describe the findings for Linehan et al. (2006) study on DBT

Answer 62

• DBT led to less dropout and less change in therapist (common problem) than the community treatment by experts (CTBE)
• DBT had 1/2 the rate of suicide attempts than CTBE -> impressive especially when we think about how most people who attempt suicide end up going to the emergency room and using those services
• No difference in non-suicidal self-injury between treatments
• DBT had less use of crisis services and fewer hospital admissions than CTBE
• Depression, suicidal ideation, and reasons for living improved in both conditions
• Good evidence for how DBT can be helpful in these outcomes that we care about (people’s ability to stay alive and to decrease their use of crisis services that tend to be expensive)

Question 63

Describe other research evidence for DBT

Answer 63

• A shortened version of DBT found to be efficacious for self-harm, suicidal ideation, and depressive symptoms for adolescents -> important right now because rates of these things are high in adolescents, especially in adolescent girls (this is often used in adolescent services)
• Found efficacy data for treating BN and BED (binge eating types of disorders), but no evidence of superiority over CBT
• Makes sense because this is an impulsive type of maladaptive behaviour that often occurs in response to emotions
• Preliminary evidence that DBT skills can be used as a stand-alone treatment for a variety of conditions
• Just taking out the DBT skills and not doing the full treatment package which requires a lot of resources can be helpful
• Often something that student therapists would use with clients
• You can pick and choose some of the skills without offering the other aspects of the package
• This is done a lot

Question 64

Describe Moore et al. (2018) study on DBT

Answer 64

• Using DBT in a forensic setting
• Example of how we can apply DBT beyond what it was initially intended for
• 8-week skills group in jail setting for male inmates who weren’t selected for any kind of emotional or behavioural problems (n = 16 with complete data)
• Prior research had tested DBT in a forensic setting but specifically for people who showed some evidence of maybe having problems in these areas that DBT targets
• This was for everyone with the idea that these problems may be present and may have led to the crime
• Very hard to do this study -> they only had 16 people who completed the study, completed the baselines assessments, went through the group, and then did the follow-up assessment to be able to see whether their symptoms changed, there were a lot of barriers to be able to administer something like this in the forensic setting
• No statistically significant changes in coping skills or emotional/behavioural dysregulation (their main outcomes - measured using a personality inventory), likely owing to small sample size
• They found that the baseline and the follow-up scores on that personality inventory were so highly correlated, suggesting there wasn’t a lot of change (but maybe we wouldn’t expect a lot of change in just 8 weeks for anyone)
• Participant feedback generally positive -> they generally enjoyed the groups
• The more structured the group was the more the group facilitator seemed much more motivated than their other groups
• Their preferences were to have the group be longer both in terms of the length of each session and the number of sessions
• This suggests that they felt like they were really getting something out of it
• Questions about whether this is simply due to it being a research study

Question 65

Describe Mediation

Answer 65

• Answers questions about why/how
• Ex: Why do people experience less depression when undergoing
  behavioural activation compared to psychodynamic therapy?
• Seeking to test an explanation for a phenomenon and specifically looking at the mechanism that would lead to less depression in one treatment vs another
• Tells us about mechanisms of intervention
• How do interventions work? How do they bring about their outcomes? What does that tell us about what we can do in terms of improving treatments
• Ex: we have a relationship between an independent variable and a dependent variable which is depicted as a direct relationship, but mediation will tell us whether this relationship might be explained or mediated by another variable
• An independent variable predicting a mediator and a mediator predicting a dependent variable
• The statistical way that we depict mediation (we have a 3rd variable that’s accounting for the relationship between the independent and the dependent variable)

Question 66

Describe moderation

Answer 66

• Answers questions about for whom/to what extent
• Question about presence or degree
• Ex: Who benefits the most from behavioural activation, compared to psychodynamic therapy, in terms of depressive symptoms?
• For some people those treatments might have equal benefits for depression, whereas for other people, behavioural activation may be extremely beneficial or extremely outweigh the benefits of psychodynamic therapy and this would be important to know in terms of treatment selection
• Tells us about individual differences in response to an intervention
• The 3rd variable is influencing the strength or the direction of the relationship between the independent and the dependent variable

Question 67

Why would we target mechanisms?

Answer 67

• Historically, treatment development has focused on reduction of particular psychological symptoms and remission of particular psychological disorders
• What are the problems with this? -> it’s based on our way of conceptualizing and diagnosing psychological disorders which is based on the DSM
• There are many limitations and criticisms of the DSM and the way of conceptualizing psychological disorders according to the DSM
• One of these problems is that there’s excessive co-occurrence among psychological disorders
• If people have one psychological disorder, it’s very likely that they have another psychological disorder and it’s likely that those 2 things aren’t operating completely independently
• Ex: if we have a treatment for depression but the person also has a substance-use disorder, we then potentially have to make a decision about what to treat first and we’re treating these as 2 separate things even though they may have many common mechanisms underlying them
• Many risk and maintenance mechanisms are common to
  multiple psychological disorders
• Treatments that focus on those underlying mechanisms or those relationships among symptoms are going to be more holistic or comprehensive than one’s that treat the symptoms as separate and unrelated
• Examples of common mechanisms: avoidance, emotion regulation, experiential avoidance

Question 68

Process-based treatment targets what?

Answer 68

Mechanisms

Question 69

Describe how we conduct research for Process-based therapy

Answer 69

• Not what therapy works better for a specific diagnosis, on average, (outcome-based therapy -> focused on the outcome or symptoms) but:
• “What treatment, by whom, is most effective for this individual with that specific problem, under which set of circumstances, and how does it come about?” (Paul, 1969) -> process-based therapy is based on this dated quote (quote indicates something that we haven’t achieved in psychotherapy to date)
• Movement towards process-based therapy (vs outcome-based therapy):
• How does change come about? What are the core change mechanisms?
• How exactly is it that treatment assignment relates differentially to outcomes? What are the mechanisms that explain why one treatment might be more helpful than another treatment?
• What change procedures (therapeutic techniques) are most effective at targeting core mechanisms?
• What specific treatment methods work best for different populations or under specific circumstances? (question of moderation)
• We need a lot more contextual info to be able to decide how to move forward with treatment
• Process-based therapy is trying to figure out the maintenance processes/mechanisms that are operating for a particular individual and designing treatments based on that person’s underlying maintenance mechanisms
• Goes from traditional RCTs focused on the outcomes of different manualized or protocolized-based treatments to studies designed to identify mediators and moderators
• Often outcome studies or RCTs will then post-hoc look at mediators or moderators but they’re not necessarily designed to answer these questions so they’re not as well set up as they could be from the get go to look at mediators and moderators
• Move from nomothetic to idiographic research methods

Question 70

Describe how process-based therapy studies work to identify mediators

Answer 70

• Mediation: what process/mechanism links therapeutic technique to outcome?
• Core requirements for calling something a mediator or a mechanism:
  1) Need to establish that mechanism is malleable
• It can be changed
• If we’re talking about treatments, then our thing that underlies the effectiveness of our treatment or treatment technique needs to actually be changeable
• If we’re talking about something that doesn’t actually change overtime, then it can’t underlie change in symptoms
  2) Mechanism relates strongly to both intervention (independent variable) and outcome (dependent variable)
  3) Effect is specific and replicable across studies
  4) A timeline is established, such that change in mechanism precedes change in outcome
• There needs to be some temporal association to be able to establish something similar to causality
• You start the treatment, the treatment first changes the mechanism, and then change in the mechanism predicts later change in the outcome
• Ex: Dimidjan article looking at behavioural activation in pregnant women -> they set up their study by having change in the mechanism be assessed at the start of treatment, at 3 months and then change in the symptoms from 3 months to follow-up (this establishes temporal nature)
  5) Statistically significant mediation does not equal a mechanism
• Also, just because someone uses the statistical technique of mediation in a paper doesn’t mean that they’ve identified the mediator -> people misuse that technique a lot

Question 71

Describe how process-based therapy studies work to identify moderators

Answer 71

• Moderation: what characteristics predict who will benefit from a particular treatment?
• Most often, demographic factors and other “moderators of convenience” (some kind of baseline measure) are tested
• Can identify moderators based on knowledge of mechanisms, and moderator studies can further inform us
  about mechanisms
• If we find a particular mechanism to be important, we can think about what would influence the degree of importance of that mechanism for a particular individual -> this can lead us down a whole different path of moderators

Question 72

Describe how process-based therapy studies move from nomothetic to idiographic research methods

Answer 72

• Moving from nomothetic (group-level) to ideographic research methods
• Here we’re studying individuals
• We can look at how similar a bunch of individuals are on their mechanisms
• We don’t necessarily know that they’re going to be similar but we’re trying to figure out the processes that underlie symptom maintenance for a particular person
• How is the psychological/problem behaviour being maintained?
• What happens to the behaviour when the contingencies are changed?
• How do we get this info?
• Historically, people were filling out report records, ABC records, self-monitoring, thought records -> paper and pencil
• Now we have other ways of gathering data that can be potentially more convenient for people and can give us a lot more data
• Functional analysis (antecedent, behaviour, consequence)
• Test, through experimental manipulation, each hypothesized function
• Using EMA and passive sensing data to create personalized models of maintaining processes
• Statistical approaches, like network modelling, can be used to understand the connections among all the processes/things that are relevant for a particular person (their symptoms and their maintenance mechanisms)

Question 73

Describe EMA and passive sensing data collection

Answer 73

• Ecological Momentary Assessment (EMA)
• More of a research method
• People use their personal cellphone and provide data multiple times per day for multiple days of the week
• We get a representative sample of how things look in their natural environment
• A lot of people are combining this self-report data with passive sensing data (either from a phone -> your phone keeps track of how much time you spend on the phone, what apps you’re using and how much time you spend on each app, fitness watches -> activity monitoring, can keep track of your steps, your heart rate, your skin conductance)

Question 74

Describe Process-Based Therapy Practice

Answer 74

• The idea is that you identify the processes that are operating for the person and then you use particular procedures or techniques to try and change those
• Examples of change processes/mechanism vs change procedures
• Cognitive defusion vs mindfulness (you’re very fused and want to lead towards cognitive defusion through mindfulness)
• Avoidance (avoiding a feared stimulus) vs exposure
• Emotion regulation vs cognitive reappraisal (having trouble with emotion regulation and with acting in accordance with goals, when experiencing negative emotions -> work on this through cognitive reappraisal or thought restructuring

Question 75

Describe Personalizing Psychotherapy

Answer 75

• Sauer-Zavala is doing a lot of work in this area
• Psychotherapy is always personalized to some extent but much of that personalization is coming from clinician judgement or patient preferences
• We use what the patient tells us and our own judgement to figure out how to adapt an evidence-based treatment that’s been shown to work empirically in the research literature
• Concern with this is that the decisions in terms of where to personalize and how to personalize are not necessarily evidence-based
• That’s the part that’s based in other things than the evidence
• The mission of this research is how to make evidence-based decisions in terms of personalizing psychotherapy

Question 76

What are the dimensions on which to personalize psychotherapy?

Answer 76

1) Diagnosis
- Someone with a psychotic disorder and another with a major depression disorder have psychotherapies that look different
2) Specific symptoms/psychological processes or mechanisms that the person presents with
3) Personality traits
- If someone is very disagreeable, the psychotherapy relationship is probably going to have to look different and there’s going to need to be more attention on the relationship
4) Pre-existing psychological skills (capitalization vs compensation)
- The degree to which you personalize based on pre-existing psychological skills and whether you would go towards more capitalization (enhancing strengths) vs compensation (specifically targeting weaknesses in terms of a particular therapy, where people start out)
5) Response to treatment (and reasons for lack of response)
- Are they responding? Are you going to do something different? VS if they’re not responding over the course of treatment
6) Change in psychological mechanisms over time

Question 77

Describe the characteristics of personalization psychotherapy

Answer 77

1) Treatment Selection
- You may decide to use a different treatment depending on some characteristics of the person
- Pre-treatment statistical algorithms (ex: PAI and Matching Factor)
- Pre-treatment shared decision-making
- There’s some research that takes a lot of demographic and baseline characteristic info from someone and tries to predict of 2 treatments which one they’re going to do better in (Personalized Advantage Index - PAI) -> unfortunately it hasn’t panned out that well
- If there are differences, they are very small and of all the variables they throw in the model in terms of baseline characteristics, there’s very few that actually predict a difference
2) Inclusion of therapy skills
- What therapy skills to include
- If you have different options of therapy skills
- Sometimes people develop a bunch of these and they decide which ones to include based on the patient’s presenting problem
- Modular approaches (ex: MATCH, CETA)
- Dynamic Assessment Treatment Algorithm (DATA)
3) Order of therapy skills
- Personalized factor models
- If there’s a fewer number of skills and you’re going to be able to cover all of them, what order do you go in?
- Do you go in a standardized order? Or do you consider capitalization vs compensation (do you want to start with the things that people are already good at or do you want to start with the things where people have shown a weakness)?
4) Treatment changes
- When do you make a change?
- How do you know if something is working or not working?
- You have to be collecting data (ex: your data tells you that the person isn’t getting better, then you have to make a change)
- Where do you go?
- Do you go always to the same treatment as a second-line treatment or does that decision about which treatment to choose next depend on some characteristic of the client?
- Routine Outcome Monitoring (ROM)
- Tier Treatment Navigator (TTN)
- Client Support Tools (CST)
- SMARTs
5) Session frequency
- How frequently will you have your sessions?
- Weekly
- Biweekly
6) Treatment termination
- When will you terminate/end treatment?
- Brief vs Full Treatment
- Good enough level

Question 78

Describe the Unified Protocol (UP) for Emotional Disorders

Answer 78

• Considered to be a transdiagnostic treatment
• Designed to treat people with emotional disorders -> generally this means internalizing disorders (ex: Major Depression and forms of anxiety disorders), but could also include eating disorders (some data suggests that with adaptations that focus on eating behaviour this would be a reasonable group to treat as well) and could also include BPD (maybe with some adaptations)
• Has a set of core treatment modules
• Very explicit about how these modules don’t have to be done in order (the order makes sense unless you have a different reason for doing it in a different order) and they don’t all need to be covered (very much a modular-based treatment that can be studied to be adapted based on the particular person)

Question 79

Describe the core treatment modules of the UP

Answer 79

1) Understanding emotions
- Awareness
- More for the fear of fear and panic symptoms that people tend to want to avoid
2) Increasing present-focused emotional awareness (mindfulness)
3) Increasing cognitive flexibility (work with thoughts)
4) Identifying and preventing patterns of emotional avoidance and maladaptive emotion-driven behaviours
- Trying to prevent the emotion-driven part that leads to maladaptive behaviours
5) Increasing awareness and tolerance of emotion-related physical sensations
6) Interoceptive and situation-based emotion-focused exposure

Question 80

Describe Farchione et al. (2012) study of UP for Emotional Disorders

Answer 80

• UP vs wait-list control for patients with a principal anxiety disorder
• UP improved symptoms of anxiety and depression, levels of negative and
  positive affect, and symptom interference in daily functioning
• Broader than just a treatment for one disorder in terms of what it can impact
• Effects maintained over 6-month follow-up

Question 81

Describe the limitations of the UP for Emotional Disorders

Answer 81

• No comparison to diagnosis-specific treatments
• Not clear if the transdiagnostic focus is advantageous or not
• Limited longitudinal follow-up data
• Limited data in other populations with problems with emotion regulation (ex: eating disorders, BPD, substance use disorders)
• Limited data in these groups that could be treated with this protocol because it would make sense for them to be considered to have an emotional disorder but we have a lack of data

Question 82

Describe Sauer-Zavala et al. (2022) study on Personalizing Psychotherapy

Answer 82

• Used the UP for Emotional Disorders as their basis for looking at the evidence for personalizing psychotherapy
• Used a SMART design (sequential multiple assignment randomized
  trial) testing personalization of UP
• At the beginning they gave everyone questionnaires to assess their abilities in all of those domains
• They had 2 aims with their levels of randomization:
  1) Examine the effect of personalized sequence of modules of UP on rate of symptom improvement
• Does it matter what order people receive the modules, in terms of their symptom improvement?
• 3 conditions to which participants could be randomized:
• Standard order
• Capitalization (they started with the things that people reported were relative strengths for them)
• Compensation (they started with the things that people reported were relative weaknesses for them)
• Compare personalized selection of modules to full treatment
  2) After they were in treatment for ~6 sessions, meaning they covered a few domains already (whether standard, skills, or weaknesses), they were randomized to stop there (received a brief version of the treatment) VS continue and finish the entire treatment -> this was to see whether it would still be efficacious with the brief version
• Included 70 patients with an emotional disorder (average was 3
  concurrent disorders among the people -> issue of comorbidity)
• Randomized to standard, capitalization, and compensation conditions at outset/beginning to determine where they were going to start
• After 5th or 6th session, randomized to discontinue vs receive full treatment (12 sessions) -> received 2 or 3 modules vs all 5 modules

Question 83

Describe the treatment gap as mentioned in Kazdin’s (2017) article

Answer 83

• We’re trying to improve or address the treatment gap
• Treatment gap: the difference in people who have a disorder, who are struggling, and the proportion who receive care
• WHO Mental Health Survey conducted across 14 countries: 0.9% (Nigeria) to 15.3% (US) received treatment who needed it
• Found that the treatment gap varied based on location, it was largest in Nigeria and smallest in the US
• We have a long way to go to be able to reach people who can benefit from psychotherapy
• National Comorbidity Survey-Replication in US concluded only 1/3 of people with psychiatric problem received adequate treatment
• You could be receiving treatment but it could not necessarily be enough (the right dose) or the right fit for the problem
• Reasons (a lot of this is because of the way in which psychotherapy is set up -> similar to the way we’re treated by a medical doctor):
  1) Treatment provided on a one-to-one basis
• There are group therapies, we know that they can be just as effective as individual therapies as well as more cost effective but typically people who are seeking therapy are looking for an individual psychotherapy
  2) Treatment administered by a highly trained professional
• What defines that professional differs by province or state (ex: in Quebec, to be called a psychologist, you must have a doctoral degree)
  3) Sessions held at a clinic, private office, or health-care facility (less true now)
• Typically clients have to travel to the sessions
• Less the case now, since there are lots of therapists offering online sessions since the pandemic
• But some therapists feel like the in-person nature of psychotherapy changes when it’s done online

Question 84

Describe the novel models of delivery for EBP as mentioned in Kazdin’s (2017) article

Answer 84

1) Task shifting: redistributing work to a broader range of individuals with less training and fewer qualifications
- Ex: the Dimijian article with behavioural activation in pregnant people administered by nurses or people with a masters degree and the article on brief ED treatment which was administered by psychological assistants
- If we can have more categories of people with some training but not necessarily a doctoral degree that can administer some of these psychotherapies that are amenable to manuals and training and don’t require as much off-the-cuff knowledge about how to deal with clients in major crisis
2) Best-buy interventions: selected based on cost-effective, feasible, and appropriate to implement in setting, but this isn’t necessarily the thing that you’re trying to target specifically
- Ex: preventing or working on alcohol-use to prevent various complications such as heart disease and other cardiovascular problems
- Ex: talking to people about exercise and how it has been shown to be a good first line treatment for mild depression (it’s consistent with the principles of behavioural activation) -> it’s not going to treat a severe depression, where the person is physically doing a lot less than normal, but it could be a good first line intervention
3) Disruptive innovations: distinct change from what is being done currently
- Ex: telemedicine (before this was very rare and now it’s becoming a lot more common) -> reaching more people and saving time
- Can do other things instead of commute to the doctors and wait
- Disruptive because people don’t necessarily think about these because they’re such a leap
4) Interventions in everyday settings: reach people where they’re at
- Having therapists hangout in barber shops or in religious settings
- Going to places where people go and trying to deliver info in that way
- Most likely, if there’s a large group of people, then some large % will be struggling with their mental health
5) Entertainment education: embed info on tv or radio
- Have the characters in a tv show or movie struggle with their mental health and reach out for help
- This shows people that this is normative and that this isn’t stigmatized
6) Use of social media: bring interventions to people online
- Young people are on social media so much that what we’ve determined from the research on social media is that it can be both harmful and helpful
- You can find the content that’s consistent with your disorder and you can find content that can help in your recovery (up to the individual to moderate their own content)
7) Use of technologies: internet-based or app-based treatment delivery
- This is becoming extremely common and profitable
- Can be done completely on its own (ex: through an app) or it can be linked in some way with a therapist
8) Community partnership model: partner with community organizations to develop action plans
- Figuring out with the community and the community organizations what this community needs, where people show up most and what would work best for this community in terms of delivering mental health interventions

Question 85

Describe the uses of technology in treatment

Answer 85

1) Psycho-educational or self-help formats
- Collection of “tools” designed to be educational
- Can be as simple as blogs, or we have particular people who write for lay audiences in terms of self-help
- Often these are talked about as tools and not necessarily as treatments
- Presented as “lessons”, rather than “sessions”
- They each tackle one topic
- It may be the same types of topics that would be tackled in individual sessions by a psychologist but because it’s not being moderated in any way, the language changes
- Steven Hayes (developer of ACT) 7-part ACT mini-series -> it’s like a newsletter you sign up for and it distills the concepts of ACT in a way that can reach a lot of people

2) Digital treatments
- Sometimes these will retain structure and components of original treatment
- It’ll be organized in a similar way in terms of what’s presented in the 1st, 2nd, and 3rd session
- “Session” times set aside by user for intervention -> set aside particular times in their schedule to be able to access this content (similar to what you would have with a once weekly psychotherapy)
- May have some degree of personalization (based on demographic group or presenting psychopathology)
- People are interested in to what degree these digital interventions need to reflect the person (ex: one simple change would be to reflect the person’s gender or race in that our example characters are going to have gender and race consistent names, there may be images of those characters associated) -> fairly simple
- Developments in machine learning/artificial intelligence will make greater personalization possible for these various online treatments
- User may select particular components of intervention that are most relevant (if it’s a modular-based treatment (ex: UP) they may be able to opt-in or opt-out to particular modules based on their own presenting psychopathology)

3) Digital assessment
- This can be in the form of questionnaires that are automatically scored and interpreted by a software, with info transmitted to clinician or it could just be shared with the client
- Can even interpret changes from previous reports
- Can self-monitor thoughts, mood, activities using smartphone (using a notes app or with particular software)
- Self-monitoring historically has been done with paper and pencil
- Can track non self-report phenomena, such as sleep, physical activity, speech, device usage, etc. (this is being done a lot in research and potentially could also be helpful in a treatment setting)
- This can all be transmitted either by talking to the therapist or potentially using some automatic transmission to the therapist
- Potential for “real-time” intervention (AKA “just in time adaptive interventions”)
- If someone is reporting high levels of symptoms (ex: high levels of stress), there can be resources that are deployed to their cellphones, in particular times, based on their symptoms
- These act as reminders to use particular skills and how to use those skills and it can be time-linked to an increase in symptoms
4) Digital training and dissemination
- Clinical training websites with videos and demonstrations (ex: client-therapist interactions that are not real)
- Ex: the ED organization (the academy for eating disorders) is doing this where they’re developing a training series of novel treatments (ex: integrative cognitive affective therapy) and posting this and allowing people to register to be able to receive that training
- Reach more users and lower costs (as opposed to having people have to travel to receive these trainings or have the trainer travel to individual groups/places to give the training and having to have costs associated with hosting that person, this can all be done online)
- Standardized training provided (can be more standardized because if you’re recording it, you know that everyone is getting the exact same experience, as opposed to when you go and visit different places where there may be differences in the experience that you’re giving people and this could potentially lead to differences in the way that the treatment is disseminated)

Question 86

What does the research suggest about using technology in treatment?

Answer 86

1) Digital interventions are popular (especially with younger people) and reach a lot of people
- People are searching for this info, especially now
- Waitlists aren’t as long as they were immediately during and post-pandemic, but it’s very expensive to see a private therapist and the waitlists for public therapy are extremely long so a lot of people are looking for these kinds of options
- Ex: 3/4 million people have used MoodGYM since introduced in 2001
- But completion rates are low without accompanying support
- Support: is there someone to reach out to if needed? Is there someone checking in with you? Sometimes it doesn’t even have to be a real therapist, it could be an AI chatbot
- Without some sort of accountability, people will start these programs and won’t necessarily finish them
2) Online clinics can produce clinically relevant change on a large scale
- In first year of operation, Australian online clinic MindSpot reached 2000 people, with 70% completing treatment (they had more of these check-ins with clients)
- Individual therapists can’t see that many people, even if we’re talking about short term 8 session treatments
3) Supported interventions have a greater impact than unsupported ones
- Differences not always large in magnitude
- How much support is necessary?
- Once we start adding support, especially from real people/therapists, the ability to scale up decreases and the costs increase
- Have to figure out where the sweet spot is where we get people to complete the treatment with providing them with maybe a bit of support but not so much that it’s decreasing our ability to reach as many people
4) With support, outcomes for digital interventions are similar to face-
to-face interventions
- This is encouraging because even with support, we’re able to reach more people in this digital format
- The support is not 50 mins sessions 1x/week for multiple weeks, it’s small check-ins -> we’re already decreasing therapist time
- Need larger scale studies to systematically test and compare digital vs in-person interventions
- A lot of research came out of the pandemic where people were able to compare, by using cohort designs (treated everyone in-person and then the pandemic hit and they treated everyone virtually), outcomes
- All they did was change the location so the therapists were just as involved and they had the exact same format of everything, it’s just that the treatment was done in the client’s home vs in the clinic
- Want to know how in-person treatment with a lot of support vs digital treatment with less support compare

Question 87

Describe Pacifica as an example of a technology used in treatment

Answer 87

• One of many apps
• It can be linked to your therapist
• You can talk about your mood, your daily health habits, your sleep
• If you’re feeling stressed you can access resources related to relaxation, such as mindfulness
• You can give a number rating and use emotion words to describe and you can type a bit about how you’re doing

Question 88

Describe MindSpot as an example of a technology used in treatment

Answer 88

• MindSpot is government funded
• Online clinic in Australia
• A new, free, and confidential online and telephone service that helps Australians recover from anxiety and depression
• Patients include people who want to overcome symptoms like chronic sadness & depression, chronic worry & stress, social anxiety, panic, PTSD, and OCD
• Using MindSpot is easy (you go to the website and complete an online assessment or you can call their phone line and the assessment usually takes 15 mins to complete)
• Once the assessment is completed, people are contacted to be provided with their feedback
• Depending on the results, MindSpot will either refer the user to local services that can help or start the user on a MindSpot treatment course
• 4 MindSpot courses:
  1) Wellbeing
  2) Wellbeing plus
  3) OCD
  4) PTSD
• Each treatment course lasts 10 weeks and is designed to help people recover and then stay well
• Each course involves reading new info and users are also given homework tasks to help them learn new skills and learn to master their symptoms
• Trained therapists contact users weekly to check on their progress, provide encouragement and help overcome barriers
• MindSpot has tested and evaluated their courses with more than 1000 Australians and 95% told them it was worth their time doing the course and 97% said they would refer a friend
• They have therapists or some sort of mental health professionals on-site who interpret the assessment data (the questionnaire data, the screening data) and screen people and provide referral resources for people who are probably a bit too severe for this type of intervention and otherwise they match them to the intervention that’s best for them
• It’s very self-guided except that there is support provided in terms of a weekly check-in
• Good balance in terms of reaching a lot of people but also providing some type of therapist support

Question 89

What are some future research questions regarding the use of technology in treatment?

Answer 89

1) Does the functionality of the intervention impact its efficacy?
- This is a whole area of research that typically isn’t done by psychologists but it can be done in collaboration with psychologists
- App developers looking at functionality, often with focus groups, and getting feedback on how the app is working
2) How can interventions be tailored more to the nature of the psychopathology?
- Ex: a lot of people with major depression have concentration problems
- How can we make sure that our technology doesn’t require a lot of concentration at once (ex: a long PDF)
3) How do we evaluate the efficacy of digital interventions?
- Important question
- Field is arguably moving too fast for traditional RCTs
- There’s so much development in terms of the technology whereas RCTs take so long and take so many resources
- Not necessarily a good fit for this type of intervention
4) How much support is necessary for improved outcomes and to have an impact?
- Less support = more scalable
- But less support often also means that people don’t complete the intervention and therefore, even if its scalable and you get a lot of people in, if you don’t complete it, then it suggests that it’s not going to be as helpful

Question 90

What are the different types of Single-Session Interventions

Answer 90

1) Pre-therapy or waitlist intervention to provide psychoeducation and/or to increase motivation for treatment
- We could give people some sort of reading material or something else to get them ready for therapy, so that once they come in we can hit the ground running once we start therapy
- Waitlists are long so we’re looking for something to hold them off until they actually receive a spot
- Provide some psychoeducation so that they can make some of these changes on their own before they actually start therapy
- Ex: this has been tried in Australia in an ED clinic where they’re giving people a broad overview of CBT of regular eating in a single-session intervention and they’re finding that some people are in really good shape when they finally get called off the waitlist such that they don’t need any treatment anymore or they’ve at least been able to get a good start
2) Delivered after an assessment and combined with therapeutic resources
- When you do a psychodiagnostic or cognitive assessment, this is often what happens
- Ex: you’re being tested to see if you have ADHD, you do a bunch of testing and then before your assessment is done, you meet with the psychologist and they go through your test results with you and tell you about how they’re being interpreted and they provide resources for you
- You may need more treatment than just that but it’s at least something to get you started
3) Delivered online with or without support
- Could be an intervention that’s easily accessible
- Ex: available on social media and people could access it most likely without support but there’s also potential to have some support

Question 91

What are the advantages of Single-Session Interventions

Answer 91

• Brief, so less costly than a once weekly 8-12 session therapy
• Scalable, especially if implemented online
• Reach people without financial resources to seek private pay therapy or with other barriers to seeking traditional treatment

Question 92

Describe Schleider et al. (2022) study on Single-Session Interventions

Answer 92

• Schleider has been doing a lot of work in the single-session intervention area
• The first RCT of single-session interventions for adolescent depression
• Nation-wide RCT (tried to get a representative sample from across the US) of online single-session interventions for adolescent depression
• Compared 2 single-session interventions that were specifically developed for depression: growth mindset (GM-SSI) and behavioural activation (BA-SSI) to active control (as opposed to just having some people not receive the intervention)
• Primary outcomes: hopelessness and agency post-treatment (things that they predicted these particular interventions would work on -> change mechanisms) and depressive symptoms at 3 months (3-month follow-up - big advantage of the study)
• 2452 13-16 yos randomized to 1 of 3 conditions, 86.17% reported elevated depression (had to do a depression screener to be eligible to be randomized)
• Recruited via Instagram in late 2020 (after the 1st wave of lockdowns, but still during the pandemic)
• The single-session interventions include testimonials or quotes from other people who have made progress in this area and involve a letter-writing or an activity/exercise to try and consolidate the skills (this is the last thing they do)
• GM-SSI: emphasized things like neuroplasticity, growth mindsets to persevere, the fact that personality can change (we’re not stuck in who we are and there can always be change)
• BA-SSI: values assessment, activity action plan (how are they going to increase their activity), discussion of benefits/obstacles
• Control condition: supportive SSI that encourages emotion
  expression but does not teach behavioural skills and it definitely didn’t have any skills that overlapped with the growth mindset or the behavioural activation intervention

Question 93

Describe the results of Schleider et al. (2022) study on Single-Session Interventions

Answer 93

• Decreases in depression at 3 months in GM-SSI and BA-SSI, relative to control condition (between-group ds = 0.18 (quite small); within-group (pre-to-post change) ds = 0.43-0.47 -> effect size was much larger and was large for all the interventions
• Decreases in hopelessness, and increases in agency, at post-treatment in GM-SSI and BA-SSI, relative to control condition (between-group ds = 0.15-0.31 -> small effect sizes)

Question 94

Describe the implications of Schleider et al. (2022) study on Single-Session Interventions

Answer 94

1) Small effect, but large implications considering how many youth could be reached by intervention
- This is what people who are proponents of single-session interventions say
- This is small (20-30 mins intervention 1 time) so we’re not going to expect major changes
- This is also small because it’s compared to a control intervention that still has an effect, we know that a supportive intervention is going to have some benefit
- It’s small but if you multiply it by the number of people that can be reached (the scale of that)
2) Confirms effect size (magnitude) and replicability from previous uncontrolled studies
3) Acceptability and efficacy of interventions for a diverse sample (80% of participants identified as sexual minority)
- People generally thought the intervention was positive
- This is a group that’s at risk for adolescent depression
- If they feel that this is a potential intervention option, then this could be a good fit

Question 95

What’s a between-group comparison?

Answer 95

When you compare the interventions to the control condition

Question 96

What’s a criticism of Schleider’s research on Single-Session Interventions

Answer 96

A lot of it was non-randomized -> she was just posting these interventions initially on Tumblr and people were self-selecting into the interventions

Question 97

Anterior cingulate cortex

Answer 97

• Involved in emotion, decision-making
• Often an area that’s important in terms of psychopathology and psychotherapy

Question 98

Hippocampus

Answer 98

Involved in memory processing

Question 99

Amygdala

Answer 99

Initially thought to respond specifically to threat but is also responsive to positive emotions

Question 100

Describe the cognitive hierarchy in the brain

Answer 100

• Areas of the brain that are more frontal have evolved later and are specific to humans
• These are higher in the cognitive hierarchy vs the areas that are more in the back of the brain and more central areas which are shared with many species (these are areas lower in the cognitive hierarchy)
• Higher: prefrontal cortex and anterior cingulate cortex
• Lower: hippocampus and amygdala

Question 101

What’s top-down processing?

Answer 101

• Slow, deliberate, explicit, and strategic processing that uses rule-based knowledge
• Mediated by prefrontal cortex
• This is when we’re working hard to study to be able to gain new knowledge
• Main target in CBT
• We’re trying to get people to slow down instead of automatically react and automatically have negative automatic thoughts/emotions we want them to take a second, reflect on the situation, look at the situation differently (all this is top-down processing)

Question 102

What’s bottom-up processing?

Answer 102

• Automatic, effortless, implicit, and pre-conscious processing based on salient features or stimulus and situational cues
• Things that draw our attention and we automatically make an evaluation
• Mediated by lower-order brain structures (ex: amygdala is on the lookout for emotional stimuli and for threat and when it detects threat in the environment it sets off alarm bells even if the thing is not actually threatening)
• Also changes with CBT, though not targeted as explicitly
• It’s likely the connection -> the prefrontal cortex is sort of damping down areas of the brain like the amygdala through this process of cognitive reappraisal

Question 103

Describe Psychotherapy and the Brain

Answer 103

• Linden: Cognitive restructuring is thought to increase top-down cognitive control over negative emotion, whereas medication is thought to decrease bottom-up reactivity to emotional stimuli
• Why some people who are on antidepressant medication will say that they feel less emotion in general (less negative but also less positive emotion) and that they don’t react as easily to a sad movie
• This can cause people to stop taking their medication or decide that it’s not the best treatment option for them
• With medication, you’re not learning any skills
• CBT primarily produces symptom reduction through its impact on higher-order executive functions (ex: problem solving, cognitive reappraisal, self-referential thinking)
• All of these things are targeted in CBT so it’s not surprising that these are the things that change with CBT and that we can observe changes in brain areas that correspond to these functions

Question 104

Describe depression, psychotherapy and the brain

Answer 104

• In depression we see alterations in various aspects of the pFC
• CBT alters activity in dorsolateral, ventrolateral, and medial prefrontal cortices as well as anterior and posterior cingulate cortices
• Mostly higher-order areas
• Modulation of top-down processes involved in encoding and retrieval of negative associative memories, rumination, and over-processing of irrelevant info
• One function of some of these areas is to decide what info is relevant and what’s not so being able to push out the info that maybe before was grabbing the person’s attention
• We’re changing the way that negative info is being processed

Question 105

Describe anxiety disorders, psychotherapy and the brain

Answer 105

• CBT alters activity in the same higher-order regions (dorsolateral, ventrolateral, and medial prefrontal cortices) as well as the
  amygdala, hippocampus, and anterior and medial temporal cortices
• More modulation of bottom-up structures in CBT for anxiety
• Anxiety is about hyper-vigilance to something in your environment, whether it be a particular stimuli in specific phobia, social situations or people’s faces in social anxiety disorder or something that reminds you of a traumatic event in PTSD
• We’re trying to reduce that hyper-vigilance
• Psychotherapy would reduce the amygdala reactivity to some of those stimuli that cause people anxiety
• PTSD (previously an anxiety disorder): Increased activity in anterior cingulate cortex and decreased activity in amygdala after exposure + cognitive restructuring
• Social anxiety: Decreased activity in amygdala-hippocampal region after either CBT or medication treatment
• OCD (previously an anxiety disorder): Behavior therapy and medication treatment decrease activation in orbitofrontal cortex, dorsolateral prefrontal cortex, and anterior cingulate cortex (involves higher order regions)

Question 106

Describe the Amygdala-hippocampal region

Answer 106

• The way that the amygdala and the hippocampus interact is that the amygdala sends signals about what’s emotionally relevant and what should potentially be feared and then the hippocampus will encode that into memory so that the next time you’ll have that same kind of fear reaction
• If we can get changes in that area it means that the person isn’t going to respond as automatically in the future

Question 107

Describe the basic mechanism of psychotherapy and the brain

Answer 107

• Basic mechanism: cognitive control of emotion
• The basic way that we think that psychotherapy, especially CBT, impacts the brain
• This is almost identical to what’s being done in cognitive restructuring
• We have an emotional reaction, we’re trying to think of the situation differently, in order to change our emotional reaction
• Higher-order cortical regions are involved in cognitive control
  of emotion
• Cognitive reappraisal involves increased activation of dorsolateral and ventrolateral prefrontal cortex and anterior cingulate cortex, as well as decreased activity of amygdala
• Cognitive reappraisal has been studied in healthy individuals in an experimental way so we know a lot about this specific aspect of CBT from “basic science research”
• It’s also these connections between these brain regions that we’re trying to change
• Using strategies to regulate emotions in experimental studies activates top-down processes in a manner consistent with CBT
• Teaching people cognitive reappraisal and to use this instead of expressive suppression (when you don’t show your emotion on your face) or as opposed to distraction or another type of technique

Question 108

Describe the recent research on Psychotherapy and the Brain

Answer 108

• Neuroscience research has examined change in functional connectivity between relevant brain regions after therapy
• Earlier in neuroimaging research, brain regions were looked at in isolation, but they don’t work in isolation
• We have all these neurons that are connecting each brain region to the others
• Here we’re talking about how the connections between the brain regions change after a course of psychotherapy
• Shou et al. 2017: CBT increased resting state connectivity (when they’re not doing anything, you’re just looking at the brain and not showing them any images or asking them to do any type of tasks) between amygdala and fronto-parietal network in patients with MDD and PTSD
• Young et al. 2017: Symptom improvement in either CBT or ACT for SAD was correlated with increased connectivity between the amygdala and the vm/vl- PFC during an emotion regulation task
• The more that the PFC and the amygdala are linked, the more that the PFC can work on damping down the amygdala by using strategies such as emotion regulation (cognitive reappraisal) and the better able the PFC would be to control the reactions of the amygdala that are not situationally/evolutionarily appropriate in the current state of things
• Mason et al., 2016: CBT for psychosis associated with greater connectivity between amygdala and dorsolateral PFC (dlPFC) in a social threat task
• We’re seeing increased connectivity both at resting (when no tasks are being done) as well as during relevant tasks (relevant to the patient population)

Question 109

Describe Gotnik et al. (2016) study on Mindfulness and the Brain

Answer 109

• Mindfulness can be a psychotherapy but it can also be a program
• Systematic review of 11 studies examining brain changes after 8 week MBSR program
• Increase in volume, activity, and connectivity of prefrontal cortex, cingulate cortex, insula, and hippocampus
• Decrease in amygdala activity and increased connectivity with prefrontal cortex

Question 110

Describe the video on Mindfulness and the Brain

Answer 110

• Meditation and the brain
• Positive and negative emotions look different in the brain
• Higher activity in left PFC relative to right -> optimism, creativity, joy, vitality, alertness
• Higher activity in right PFC relative to left -> depression, anxiety, distress, worry
• Study on meditators found that the left to right ratio in a Tibetan meditator was much higher than any of the other subjects that they brought into the laboratory
• They wondered if this was just random and whether he was just born happy and so decided to become a monk and meditate or if the large amount of time that he had dedicated to this practice actually had an impact
• They did an RCT where they randomly assigned biotechnology employees who had never meditated in a mindfulness group or in a waitlist group and then looked if there was change in the activity of the brain
• They found that 4 months later, there was significant differences in this left to right ratio where they had much greater activity in left to right with greater positive emotions and vitality
• In psychology there’s a happiness setpoint
• We find that people have a continuum of happiness that you’re born with and you can’t really move it too far
• What they find is that when you win the lottery, you have an increase in happiness and then a year later, you’re back to your baseline level of happiness
• If you get in a terrible accident and become paralyzed, you have a huge dip in happiness and then within one year, you’re back almost to your baseline
• This has been replicated over and over
• This is great news if you’re born happy but it isn’t good news for people who weren’t necessarily born happy
• This research shows that although changing exterior circumstances doesn’t change our “set” levels of happiness, changing our interior landscape can
• Changing our interior environment through training the mind, heart and body in these practices can shift our levels of happiness
• Happiness can be trained because the very structure of our brain can be modified
  (neuroplasticity)
• Our repeated experiences shape our brain -> what we practice becomes stronger
• Everything that we practice and every single moment matters
• Lazar found in her research that meditators and the parts of their brain that have to do with attention, concentration, emotional intelligence, get stronger and bigger (cortical thickening)
• Mindfulness practice increases grey matter density in areas associated with attention, learning, self-awareness, self-regulation, empathy and compassion
• Cortical thickening correlated with practice
• What we practice gets stronger
• Superhighways of habits: well-grooved pathways in our brain and they’re what we automatically do
• Mindfulness is helping us build a country road of compassion (clearing all the brambles in your brain) and creating a new neural pathway
• Instead of going through the superhighway of habits, we shift and go through a new pathway and every time that we do this, we’re strengthening that pathway so that eventually that pathway becomes the habit

Question 111

Describe psychopharmacology and the brain

Answer 111

• Medication treatments
• Currently SSRIs are recommended as first-line pharmacological treatment for depression
• Considered 2nd generation antidepressants and compared to the previous generation of medication (tricyclics and monoamine inhibitors):
• Side effect profile more mild (Tricyclics are often used for insomnia or sleep problems because they make people really sleepy, whereas SSRIs don’t have that effect and SSRIs have fewer sexual side effects although they still have some)
• Less fatal in case of overdose (concerned about this in the case of someone with major depression who might have suicidal ideation)
• No evidence that SSRIs are more effective or are going to help people more than these other medications, they’re just preferred for these other reasons
• Benefit of SSRIs most pronounced for severe depression (otherwise, possible placebo effect)
• Sometimes people with severe depression can’t engage in cognitive therapy because they’re not well enough so we need to do something, either behavioural activation or an antidepressant medication to get them back on their feet
• The problem with antidepressant medications is that they take a while to work (typically take 6 weeks for their full effect), but you can start seeing a difference in the first 2-4 weeks
• Research has suggested that there might be a placebo effect for mild and moderate depression when people take antidepressant medications
• When they do controlled trials, it’s not quite clear whether there’s an advantage of taking the active medication
• Most people start feeling better and discontinue use within 3 months, but course of average major depressive episode is 9 months
• It’s possible that people will discontinue the medication and then will have a relapse
• Recommended that you stay on an antidepressant medication for around a year even if you feel better and then you can decide if this is something you want to continue or discontinue

Question 112

Describe Deep-brain stimulation

Answer 112

• Interesting and emerging treatment
• Neurostimulator implanted in brain sends electrical impulses to specific subcortical regions of the brain
• Targeted -> not targeting a bunch of regions
• Depending on where you place it, it’s going to activate a particular region
• Good for research because control is built in – sham vs active stimulation
• The sham: you implant the same neurostimulator but you don’t turn it on and the person doesn’t know any different whether it’s turned on or not
• Active stimulation: they actually stimulate the area that’s been identified as being important
• Helen Mayberg (one of the pioneers of this type of research), 2005: basic research that targeted subgenual cingulate in 6 patients with treatment-resistant depression
• They’ve tried a lot of different treatments, probably including electroshock therapy, and they weren’t getting better
• 4/6 patients achieved sustained clinical response or remission at 6 months
• Even in just a short period of time, they went from having severe depression to mild-to-no depression
• This isn’t a first line treatment -> people would first be offered psychotherapy and several types of medications before getting to this point where this would be considered
• Being applied to other treatment-refractory conditions like OCD and anorexia nervosa

Question 113

Describe Reiff et al. (2020) study on psychedelic drugs as a form of treatment and the brain

Answer 113

• Very popular area right now
• Clinical application (using these drugs to treat psychiatric disorders)
• Scoping review of 161 studies on clinical application of psychedelic
  drugs for psychiatric disorders
• Psychedelics: psilocybin (serotonin agonist), lysergic acid diethylamide (LSD, serotonin agonist), ayahuasca (harmine and DMT), 3,4-Methylenedioxymethamphetamine (MDMA; many biological effects, including monoamine, serotonin, norepinephrine, and oxytocin)
• They were interested in looking at depending on the mechanism of action, if they saw differences in the effectiveness
• A lot of these are working on serotonin, specifically serotonin
• They were comparing these studies based on which drug was being used
• Typically this is the way that a psychedelic-assisted therapy would be:
• Preparatory therapy, psychedelic session(s) [high-dose of drug], processed in integrative therapy
• Most of the studies would fall in this category
• Preparatory phase: where you would get people ready for this experience that they’re going to have, do some safety planning about what would be done if they’re not feeling safe
• Then there would be 1-3 sessions where the person would take the psychedelic drug
• They would be accompanied in this experience in case something happened
• Then the sessions would be processed in some type of therapy afterwards when they’re not using the drug
• In the current research, a lot of this is high doses of the drugs (not microdosing), this is meant to have an out-of-body experience

Question 114

Describe Dworkin’s (2023) article on psychedelics for psychotherapy

Answer 114

1) Why combine psychedelics with psychotherapy?
- Why not use them similar to antidepressants where you get a prescription and that’s it?
- Issue of psychological and physical safety
- These drugs have much different effects than antidepressant medications
- Have to be monitored in some way
- Psychotherapy may enhance magnitude and duration of benefit of the drugs
2) Are these synergistic treatments?
- Is it that combining psychedelic therapy with psychotherapy is having an added benefit
- Is the effect of the whole greater than the sum of its parts?
- What these authors argue is that no one has been able to answer this question
- Needs to be tested using a factorial design
3) Test using a factorial design
- 4 conditions
- Psychedelic + psychotherapy
- Drug placebo + psychotherapy
- Psychedelic + psychotherapy placebo
- Drug placebo + psychotherapy placebo
- Unclear exactly what a psychotherapy placebo would look like
- In terms of using drug placebos, people know whether they’re on the mushrooms or nothing

Question 115

Describe Perricone et al. (2024) study on psychotherapy and the brain

Answer 115

• Intervention to change belief that psychotherapy affects the mind, but
  not the brain
• RCT where they wanted to see whether you could change beliefs about psychotherapy by giving some people some info about how psychotherapy impacts the brain
• A lot of people don’t realize that psychotherapy impacts the brain
• They think medication impacts the brain but not therapy
• Participants with elevated depression, people from general population, and mental health clinicians
• Pre-test (case description), biological explanation of depression (stating that depression has biological underpinnings and specifically focused on serotonin theory) followed by randomization to one of 3 conditions: brain-level psychotherapy description (describing psychotherapy and how it impacts the brain), mind-level psychotherapy description (active control - describing psychotherapy and talking about things that change such as emotion, cognitive reappraisal, has benefit but not necessarily within the brain), or inactive control
• Results:
• Biological explanation + inactive control = psychotherapy less effective than at the beginning of the study (because of the biology part)
• Biological explanation + brain-level psychotherapy description = psychotherapy more effective (confidence in psychotherapy increases)
• Biological explanation + mind-level psychotherapy condition = no change
• Why it’s important to include a lecture on psychotherapy and the brain so that people know that it has these effects and that it’s not just medication or biological treatment that impact the brain

Question 116

Describe the findings of Sauer-Zavala et al. (2022) study on Personalizing Psychotherapy

Answer 116

• In the standard way, basically everyone received the initial modules
• In compensation, there was more in understanding emotions, mindful emotion awareness, and countering emotional behaviours
• In capitalization, people were more likely to receive countering emotional behaviours and confronting physical sensations
• This indicates that most people are probably better at those latter things than the first things
• Capitalization is a different way of presenting the info
• There wasn’t a lot of difference in terms of satisfaction and acceptability of the treatment
• They found that in general, people liked the standard and the capitalization versions a bit better than the compensation
• In terms of the personalization, they liked starting with the things that they were better at than the things that they were worse at
• They also preferred the full treatment to the brief treatment -> most likely it’s more credible and seems more like a regular length of treatment
• In terms of actual symptom outcomes, they measured anxiety, depression, and overall clinical severity -> they didn’t find any differences between the conditions
• Good to know that it could be shortened and that the modules could be potentially moved around to enhance personalization