Skill Acquisition During Transdiagnostic Treatment With the Unified Protocol

Are the ways women cope with stressors related to their health behaviors over time?

OBJECTIVE

Emerging research suggests the use of certain strategies to cope with stressors relate to disease and mortality risk, and lifestyle habits may be underlying mechanisms. Studies show psychological symptoms (eg, anxiety) and states (eg, happiness) predict the likelihood of adopting an integrated lifestyle that encompasses key health-related behaviors, like smoking. Yet, whether psychological processes, including stress-related coping, influence the adoption of a healthy lifestyle is unknown. We investigated whether coping strategies typically deemed adaptive (eg, seeking emotional support) and maladaptive (eg, denial) relate to sustaining a healthy lifestyle over a 16-year follow-up. We also explored whether variability in the use of these strategies, reflecting attempts to find the best strategy for a given stressor, subsequently relates to lifestyle.

METHODS

Women (N = 46 067) from the Nurses' Health Study II cohort reported their use of 8 coping strategies in 2001, from which we also derived coping variability levels (lower, moderate, greater). Health behaviors (eg, physical activity, smoking, sleep), self-reported every 4 years from baseline until 2017, were combined into a lifestyle score. Generalized estimating equations, controlling for baseline demographics and health-related factors, were performed.

RESULTS

Most adaptive strategies and greater variability levels were associated with a higher likelihood of sustaining a healthy lifestyle (eg, active coping, relative risk [RR] = 1.09, 95% confidence interval [CI], 1.08-1.11), with the reverse evident with maladaptive strategies (eg, behavioral disengagement, RR = 0.94, CI, 0.93-0.95), but some unexpected results also emerged.

CONCLUSIONS

Findings highlight the importance of going beyond the usual (mal)adaptive categorization of coping strategies when investigating their predictive value with behavioral outcomes.

Internet-based UP-A intervention on treatment of stress, anxiety, depression, and psychological flexibility among adolescents with sub-clinical diagnosis of emotional disorders during the COVID-19 pandemic: a clinical trial

This clinical trial aims to assess the effectiveness of internet-based Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents (UP-A) during the COVID-19 pandemic in reducing stress, anxiety, and depression, and psychological flexibility. 40 adolescents with subclinical features of emotional disorder randomly divided into two groups of intervention and control. The participants first completed DASS-21 and AAQ-2 questionnare online. Then, the intervention group received 12 sessions of UP-A through video calls on WhatsApp, 2 days per week each for 45 min. UP-A is an emotion-focused, cognitive-behavioral therapy consisting of 5 core modules or components that target temperamental characteristics, particularly neuroticism and resulting emotion dysregulation. Eventually the stress, anxiety, and depression levels decreased in intervention group and their psychological flexibility increased immediately and 3 months after the intervention. Clinical trial registration This study was registered by Iranian Registry of Clinical Trials (Prospective, ID: IRCT20210428051113N1, Registration date: 14/06/2021; https://en.irct.ir/trial/55900 ).

Within-person changes in aversive reactivity predict session-to-session reductions in anxiety and depression in the unified protocol

ABSTRACTThe Unified Protocol (UP) theoretically leads to reductions in emotional disorder symptoms by reducing aversive reactions to emotions. However, aversive reactions can take many forms (e.g., non-acceptance, behavioral avoidance). We examined if (1) multiple aspects of aversive reactivity predicted session-to-session changes in anxiety and depression in the UP, (2) these aspects reflected a single latent construct, and (3) changes in this latent construct predicted changes in anxiety and depression. Participants (N = 70, Mage = 33.74, 67.1% female, 74.3% white) completed six sessions of UP modules and measures of aversive reactivity, anxiety, and depression before each session. We used hierarchical linear modeling and random-intercept cross-lagged panel models to test aspects of aversive reactivity and a latent factor of aversive reactivity, respectively, as predictors of session-to-session changes in anxiety and depression. Within-person improvements in four of five aspects of aversive reactivity predicted decreases in anxiety, and improvements in two aspects predicted decreases in depression. However, within-person improvements in latent aversive reactivity predicted decreases in anxiety at five sessions and in depression across all sessions. These results add to the growing literature highlighting the role of aversive reactivity as a potential transdiagnostic process involved in improvements in emotional disorder symptoms during treatment.

Skill Use Mediates the Within-Person Effect of the Alliance on Session-to-Session Changes in Anxiety and Depression in the Unified Protocol

Objective

Both the therapeutic alliance and the specific skills taught in treatment are thought to contribute to change in cognitive-behavior therapy (CBT), but it is unclear if or how these processes influence each other and outcomes in treatment. We tested the hypothesis that the degree to which patients used CBT skills would mediate the relation between the alliance and session-to-session changes in anxiety and depression.

Method

Adult participants (N = 70; Mage = 33.74, 67% female, 70% White) with emotional disorders were randomized to receive 6 or 12 sessions of the Unified Protocol. Before each session, participants reported anxiety and depression severity and past-week skillfulness. After each session, participants rated the strength of the alliance. We tested whether greater within-person skillfulness mediated the relation between within-person alliance strength and session-to-session changes in anxiety and depression.

Results

Skillfulness significantly mediated the effect of the alliance on session-to-session changes in anxiety, ab = -.02, p = .04, and depression, ab = -.02, p = .02, such that a stronger alliance predicted greater next-session skillfulness, which predicted session-to-session decreases in anxiety and depression. When alliance subscales were examined separately, the strongest effect was observed for agreement on therapy tasks.

Conclusions

Improvements in the alliance may facilitate skill use and indirectly predict reductions in anxiety and depression through skill use in CBT. We encourage research on how to enhance both the alliance and skillfulness in CBT.

Do Unified Protocol modules exert general or unique effects on anxiety, depression, and transdiagnostic targets?

Several transdiagnostic cognitive-behavior therapies include multiple treatment components. However, it is unclear whether some components are more efficacious than others at reducing symptoms or whether these components uniquely influence their putative mechanism of change. Participants (N = 70; Mage = 33.7; 67.1% female, 74.3% White) with a primary anxiety or depressive disorder were randomized to one of three standard or personalized sequences of core Unified Protocol modules. Using hierarchical linear modeling, we tested (a) whether the average session-to-session change in anxiety and depression differed between modules and (b) whether the average session-to-session change in the putative mechanism of each module differed between modules. All modules led to similar changes in anxiety, but Confronting Physical Sensations led to significantly less change in depression than other modules. There were no significant differences among modules predicting putative mechanisms of change, although there was a trend for Mindful Emotion Awareness to predict greater improvements in mindfulness than Understanding Emotions. Consistent with its transdiagnostic nature, UP modules may exert similar effects on anxiety and putative mechanisms of change, although interoceptive exposures may be less impactful for changing depressive symptoms and the mindfulness module may promote relatively specific improvements in mindfulness.

Enhancing Internet-based psychotherapy for adults with emotional disorders using ecological momentary assessments and interventions: Study protocol of a feasibility trial with "My EMI, Emotional Well-being" app

Introduction

Emotional disorders are the most frequent mental health problems globally. To ensure the dissemination of psychological treatments for these conditions, novel forms of delivery (e.g., Internet or mobile apps) and more scalable forms of psychotherapy (e.g., transdiagnostic interventions) have become increasingly popular. Research, however, shows that a significant number of patients, around 40 % according to some studies, do not respond to the interventions as expected (i.e., not-on-track patients). Ecological momentary assessments (EMAs) and ecological momentary interventions (EMIs) could simplify tailoring treatments to the patients' progress and rapidly respond to undesired outcomes during psychotherapy. Therefore, these would facilitate measurement-based care with little therapist involvement. This study aims to explore the feasibility of an app-based system called My EMI, Emotional Well-being for people with emotional disorders. According to daily EMAs, the app will provide personalized EMIs while participants receive a self-applied online transdiagnostic treatment. The app will be used as an add-tool to the online intervention to address emotion dysregulation, foster adherence, and reinforce contents. The current study describes the study protocol for this trial.

Method and analysis

A single-group, open trial design will be used. Participants will be 30 adults suffering from emotional disorders. Primary outcomes will be app usability, acceptability, and response rates. Secondary outcomes will be either evaluated in Qualtrics at pre-treatment, post-treatment, and 3-month follow-up (depression and anxiety severity, and transdiagnostic dimensions of emotional disorders) or daily throughout the study with the app (EMAs of mood and five transdiagnostic mechanisms of therapeutic change). EMIs will consist of brief, evidence-based transdiagnostic CBT digital content (images, infographics, or videos) delivered just-in-time. Only if problems persist, short phone calls or episodic videocalls will be conducted. The Ethics Committee of the Jaume I University approved the study and all its procedures (CD/111/2021) in December 2021.

Discussion

Identifying personalized and scalable interventions is paramount to improve mental health care, especially its accessibility, and to reduce the psychological distress of people with mental health problems. Feasibility data of the app (EMA and EMI system) supported by a self-applied online transdiagnostic intervention will be important to explore whether this modern approach is a real option to move forward personalized psychological interventions for persons with emotional disorders.

Trial registration

ClinicalTrials.gov Identifier: NCT05109780. Registered 05 November 2021, https://clinicaltrials.gov/ct2/show/NCT05109780.