Compassion-focused therapy: Preface and introduction for special section

Efficacy of the my health too online cognitive behavioral therapy program for healthcare workers during the COVID-19 pandemic: A randomized controlled trial

Background

Healthcare workers' mental health has been impacted by the COVID-19 pandemic, emphasizing the need for mental health interventions in this population. Online cognitive behavioral therapy (CBT) is efficient to reduce stress and may reach numerous professionals. We developed "MyHealthToo", an online CBT program to help reduce stress among healthcare workers during the COVID-19 pandemic.

Objective

The aim of our study is to investigate the efficacy of an online CBT program on stress and mental health conditions among healthcare workers during a health crisis.

Methods

We performed a multicentric randomized controlled trial among 155 participants allocated either to the experimental or active control group (bibliotherapy). The primary outcome was the decrease of perceived stress scores (PSS-10) post-treatment. Secondary outcomes included depression, insomnia and PTSD symptoms along with self-reported resilience and ruminations. Assessments were scheduled pretreatment, mid-treatment (4 weeks), post-treatment (8 weeks), and at 1-month and 4-months follow-up.

Results

For both interventions, mean changes on the PSS-10 were significant post-therapy (W8), as at 1-month (W12) and 4-months (W24) follow-ups. The between-group comparison showed no difference at any time point (ps > 0.88). Work-related ruminations significantly decreased in the experimental group with a significant between-group difference at W8 (Δ = -1.83 [-3.57; -0.09], p = 0.04). Posttraumatic stress symptoms significantly decreased in the experimental group with a significant between-group difference at W12 (Δ = -1.41 [-2.68; -0.14], p = 0.03). The decrease in work-related ruminations at W8 mediated the decrease in posttraumatic stress symptoms at W12 (p = 0.048).

Conclusion

The "MyHealthToo" online CBT intervention may help reduce ruminations about work and posttraumatic stress symptoms among healthcare workers during a major health crisis. Work-related ruminations may represent a relevant target of online interventions to improve mental health among healthcare workers.

Effects of Meditation Training and Non-Native Language Training on Cognition in Older Adults: A Secondary Analysis of a Randomized Clinical Trial

Importance

Nonpharmacological interventions are a potential strategy to maintain or promote cognitive functioning in older adults.

Objective

To investigate the effects of 18 months' meditation training and 18 months' non-native language training on cognition in older adults.

Design, Setting, and Participants

This study was a secondary analysis of the Age-Well trial, an 18-month, observer-masked, randomized clinical trial with 3 parallel arms. Eligible participants were community-dwelling adults aged 65 years and older residing in Caen, France. Participants were enrolled from November 24, 2016, to March 5, 2018, and randomly assigned (1:1:1) to meditation training, non-native language (English) training, or no intervention arms. Final follow-up was completed on February 6, 2020. Data were analyzed between December 2021 and November 2022.

Interventions

The 18-month meditation and non-native language training interventions were structurally equivalent and included 2-hour weekly group sessions, daily home practice of 20 minutes or longer, and 1 day of more intensive home practice. The no intervention group was instructed not to change their habits and to continue living as usual.

Main Outcomes and Measures

Cognition (a prespecified secondary outcome of the Age-Well trial) was assessed preintervention and postintervention via the Preclinical Alzheimer Cognitive Composite 5 (PACC5), and composites assessing episodic memory, executive function, and attention.

Results

Among 137 randomized participants, 2 were excluded for not meeting eligibility criteria, leaving 135 (mean [SD] age, 69.3 [3.8] years; 83 female [61%]) eligible for analysis. One participant among the remaining 135 did not complete the trial. In adjusted mixed effects models, no interaction effects were observed between visit and group for PACC5 (F2,131.39 = 2.58; P = .08), episodic memory (F2,131.60 = 2.34; P = .10), executive function (F2,131.26 = 0.89; P = .41), or attention (F2,131.20 = 0.34; P = .79). Results remained substantively unchanged across sensitivity and exploratory analyses.

Conclusions and Relevance

In this secondary analysis of an 18-month randomized trial, meditation and non-native language training did not confer salutary cognitive effects. Although further analyses are needed to explore the effects of these interventions on other relevant outcomes related to aging and well-being, these findings did not support the use of these interventions for enhancing cognition in cognitively healthy older adults.

Trial Registration

ClinicalTrials.gov Identifier: NCT02977819.

The Self-Compassion Scale-Short Form: Psychometric evaluation in one non-clinical and two clinical Swedish samples

BACKGROUND

Self-compassion has been defined as the ability to be with one's feelings of suffering in a warm and caring way. Research has shown a negative association between self-compassion and mental illness, and that low self-compassion can make psychotherapeutic effects less likely. The ability to measure a patient's self-compassion in a fast and reliable way is therefore important in investigating effects of psychotherapies. The aim of the present study was to evaluate the psychometric properties of the Swedish version of the Self-Compassion Scale-Short Form (SCS-SF) in both non-clinical (NC) and clinical samples.

METHODS

Cross-sectional data were gathered in a NC community sample (n = 1,089), an eating disorder (ED) sample (n = 253) and a borderline personality disorder (BPD) sample (n = 151). All participants were asked to complete a number of questionnaires, including the SCS-SF, and 121 participants in the NC sample repeated the assessment after 2 weeks for test-retest analysis.

RESULTS

Confirmatory factor analyses supported the first-order model suggested in previous research. Good internal consistency (Cronbach's alpha = 0.78-0.87) and test-retest reliability (intra-class correlation = 0.84) were demonstrated for the entire scale. Results also showed good convergent validity, demonstrating moderate negative associations between self-compassion and mental illnesses, as expected, and acceptable divergent validity, demonstrating weak positive associations between self-compassion and quality of life and mindfulness.

DISCUSSION

The correlations between the SCS-SF and the instruments used for validation were weaker in the clinical samples than the NC sample. This may be due to difficulties measuring these constructs or that the associations differ somewhat between different populations, which could warrant further research. The results added some support to the assumption that self-compassion may overlap with mindfulness yet still represents a distinct construct.

CONCLUSIONS

Analyses of the SCS-SF provided evidence of adequate to good psychometric properties, supporting use of the scale's total sum score and a first-order factor structure. This is in accordance with previous evaluations of the SCS-SF, suggesting that it is a reliable and time-efficient instrument for measuring a general level of self-compassion. This may be important when evaluating psychotherapy and investigating self-compassion and its influence on psychiatric illness.

Parents’/caregivers’ fears and concerns about their child’s epilepsy: A scoping review

Background

Childhood epilepsy is a serious and common neurological condition and can have life-long consequences and its impact can pervade all aspects of family life. Whilst the medical management of seizures is important, much of the day-to-day home management of epilepsy is invisible to people external to the family, including health care professionals, and parents’/caregivers’ fears and concerns can go unacknowledged and unaddressed by health care professionals.

Objective

This objective of this review was to examine parents’/caregivers’ fears and concerns regarding their child’s epilepsy, the impact of these fears and concerns on family life, the social and emotional well-being of parents/caregivers and any factors which mitigate these fears and concerns.

Design

Scoping review using a modified version of Arksey and O’Malley’s framework.

Data sources

Relevant studies were identified using key search terms in Scopus, Medline, CINAHL and PsychInfo databases in March 2021 with hand checking of reference lists. Search terms were developed using population (parents/caregivers of children aged ≤ 18 years with epilepsy, families); concept (parents’/caregivers’ fears, concerns, anxiety about their child’s epilepsy); and context (any setting). A further search was run in April 2022. Other inclusion criteria: English language empirical studies, 2010–2021.

Study appraisal methods

A minimum of two reviewers independently screened articles and undertook data extraction and decisions were consensually made.

Methodological quality appraisal was undertaken using the Mixed Methods Appraisal Tool v2018. A data extraction table was created to chart all studies. The conduct and reporting of this study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (S1 Table). There is no published copy of the review protocol.

Main findings

The search identified a total of 4077 papers (after duplicates were removed) of which 110 were assessed for eligibility. Twenty-four papers published between 2010–2021 were included in the review and each paper was treated as a separate study. The review findings indicate that parents’/caregivers’ fears and concerns stem from more than their child’s seizures and relate to many wider aspects of family life. These fears and concerns had far-reaching influences on their parenting/caregiving, and on the lifestyle and activities of their child and their family. What was less evident was what parents/caregivers wanted in terms of support or how they thought health professionals could acknowledge and/or allay their fears and concerns. The discussion is framed within the compassion-focused therapy model as a basis for generating new thinking about the impact of these fears and concerns and the need for a new agenda for clinical consultations in childhood epilepsy.

Conclusions

The review concludes with a proposal that a more compassionate agenda underpins the dialogue between parents/caregivers and clinicians to encompass and mitigate the wider emotional, psychosocial, and societal threats that impact on the parent/caregivers of children with epilepsy.

My Health Too: Investigating the Feasibility and the Acceptability of an Internet-Based Cognitive-Behavioral Therapy Program Developed for Healthcare Workers

Background: The COVID-19 crisis has had a considerable mental health impact on healthcare workers. High levels of psychological distress are expected to have a significant impact on healthcare systems, warranting the need for evidence-based psychological interventions targeting stress and fostering resilience in this population. Online cognitive behavioral therapy (CBT) has proved to be effective in targeting stress and promoting resilience. However, online CBT programs targeting stress in healthcare workers are lacking. Objective: The aim of our study is to evaluate the feasibility and acceptability of an internet-based CBT intervention, the My Health Too program we developed during the first COVID-19 epidemic peak in France. Methods: We recruited 10 participants among Alsace region hospital staff during the first peak of the pandemic in France. They were given 1 week to test the website and were then asked to answer an internet survey and a semi-structured phone interview. Results: We conducted a thematic analysis of the content from the phone interviews. Major themes were identified, discussed and coded: the technical aspects, the content of the website and its impact on participants' emotions and everyday life. Overall, the participants reported finding the website easy to use and interactive. They described the resources as easy to understand, readily usable, and useful in inducing calm and in helping them practice self-compassion. Conclusion: Our results suggest that the My Health Too online CBT program is highly feasible and acceptable to healthcare workers during the highly stressful times of the pandemic peak. The feedback provided helped to improve the program whose efficacy is to be tested.

Factorial Structure and Construct Validity of an Iranian Version of the Fear of Compassion Scale: A Study in Nurses

Backgrounds:

Fear of compassion is one of the psychological variables in the nursing profession that can be a barrier to providing appropriate services to patients. This research was done in order to assess psychometric properties, construct validity, reliability of fear of compassion scales and to introduce suitable measures for experts and researchers in the healthcare-related fields.

Materials and Methods:

In this study, 216 nurses (117 males and 99 females) were chosen with a multistage cluster sampling method between June 2016 and Feb 2017. Lisrel-8 and SSPS-18 were used for data analysis. The construct validity of the fear of compassion scales was assessed using confirmatory factor analysis. To assess the divergent and convergent validity of the fear of compassion scales, the compassion for others, depression, anxiety, stress, burnout, and cognitive emotion regulation questionnaires were used.

Results:

The results of confirmatory factor analysis showed that the single-factor model of fear of compassion scales (for others, from others, and for self) is a better fit to the data. Furthermore, these three scales had a positive and significant correlation with anxiety, depression, stress, burnout, and unhealthy cognitive-emotion regulation strategies, and negative and significant correlation with compassion for others and healthy cognitive-emotion regulation strategies. In addition, the Cronbach's alpha coefficient for fear of expressing compassion to others was 0.85, and 0.95 and 0.96 for fear of responding to compassion from others and fear of self-compassion, respectively.

Conclusions:

This study provides additional evidence for the psychometric properties of fear of compassion scales in Iranian nurses.

Psychotherapy in the Framework of Embodied Cognition-Does Interpersonal Synchrony Influence Therapy Success?

Mental health problems remain among the main generators of costs within and beyond the health care system. Psychotherapy, the tool of choice in their treatment, is qualified by social interaction, and cooperation within the therapist-patient-dyad. Research into the factors influencing therapy success to date is neither exhaustive nor conclusive. Among many others, the quality of the relationship between therapist and patient stands out regardless of the followed psychotherapy school. Emerging research points to a connection between interpersonal synchronization within the sessions and therapy outcome. Consequently, it can be considered significant for the shaping of this relationship. The framework of Embodied Cognition assumes bodily and neuronal correlates of thinking. Therefore, the present paper reviews investigations on interpersonal, non-verbal synchrony in two domains: firstly, studies on interpersonal synchrony in psychotherapy are reviewed (synchronization of movement). Secondly, findings on neurological correlates of interpersonal synchrony (assessed with EEG, fMRI, fNIRS) are summarized in a narrative manner. In addition, the question is asked whether interpersonal synchrony can be achieved voluntarily on an individual level. It is concluded that there might be mechanisms which could give more insights into therapy success, but as of yet remain uninvestigated. Further, the framework of embodied cognition applies more to the current body of evidence than classical cognitivist views. Nevertheless, deeper research into interpersonal physical and neurological processes utilizing the framework of Embodied Cognition emerges as a possible route of investigation on the road to lower drop-out rates, improved and quality-controlled therapeutic interventions, thereby significantly reducing healthcare costs.

MAGIC: a Proposed Model Based on Common Factors

The author offers an initial formulation of what an approach integrating common factors and the processes of change would look like. The dodo-verdict has been extant in the psychology literature for almost 100 years, and it is time to acknowledge the veracity of the dodo-bird verdict as we move toward therapeutic approaches focusing on factors the empirical approaches have in common. Although we now have hundreds of different theoretical models, no one model appears to be superior to any other. However, certain presenting conditions may be more suited to certain interventions. The MAGIC approach introduced here incorporates client motivation, the therapeutic alliance, goal-setting, implementation, and commitment. This gives us a basic structure of commonalities around which we will be able to build comprehensive psychotherapeutic strategies drawing on intervention techniques from many different models. After a brief consideration of historical factors, I will present one idea for an integrated approach followed by a discussion of some assumptive processes which are at work in the therapeutic cadre as well as a consideration of cultural diversities.

Efficacy of an online cognitive behavioral therapy program developed for healthcare workers during the COVID-19 pandemic: the REduction of STress (REST) study protocol for a randomized controlled trial

BACKGROUND

The acknowledgment of the mental health toll of the COVID-19 epidemic in healthcare workers has increased considerably as the disease evolved into a pandemic status. Indeed, high prevalence rates of depression, sleep disorders, and post-traumatic stress disorder (PTSD) have been reported in Chinese healthcare workers during the epidemic peak. Symptoms of psychological distress are expected to be long-lasting and have a systemic impact on healthcare systems, warranting the need for evidence-based psychological treatments aiming at relieving immediate stress and preventing the onset of psychological disorders in this population. In the current COVID-19 context, internet-based interventions have the potential to circumvent the pitfalls of face-to-face formats and provide the flexibility required to facilitate accessibility to healthcare workers. Online cognitive behavioral therapy (CBT) in particular has proved to be effective in treating and preventing a number of stress-related disorders in populations other than healthcare workers. The aim of our randomized controlled trial study protocol is to evaluate the efficacy of the 'My Health too' CBT program-a program we have developed for healthcare workers facing the pandemic-on immediate perceived stress and on the emergence of psychiatric disorders at 3- and 6-month follow-up compared to an active control group (i.e., bibliotherapy).

METHODS

Powered for superiority testing, this six-site open trial involves the random assignment of 120 healthcare workers with stress levels > 16 on the Perceived Stress Scale (PSS-10) to either the 7-session online CBT program or bibliotherapy. The primary outcome is the decrease of PSS-10 scores at 8 weeks. Secondary outcomes include depression, insomnia, and PTSD symptoms; self-reported resilience and rumination; and credibility and satisfaction. Assessments are scheduled at pretreatment, mid-treatment (at 4 weeks), end of active treatment (at 8 weeks), and at 3-month and 6-month follow-up.

DISCUSSION

This is the first study assessing the efficacy and the acceptability of a brief online CBT program specifically developed for healthcare workers. Given the potential short- and long-term consequences of the COVID-19 pandemic on healthcare workers' mental health, but also on healthcare systems, our findings can significantly impact clinical practice and management of the ongoing, and probably long-lasting, health crisis.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04362358 , registered on April 24, 2020.

Exploring compassionate attributes and skills among individuals participating in compassion-focused therapy for enhancing well-being

OBJECTIVES

The conceptual approach of compassion underlying compassion-focused therapy (CFT) is based on theoretical rather than empirical grounds. The aim of the present study was to seek empirical support for components of compassion as outlined in the theoretical model underpinning CFT, and to explore which components, if any, matter most for improving well-being.

DESIGN

A sequential exploratory mixed methods design was employed.

METHODS

Alongside a randomized controlled trial (RCT), we systematically examined 625 emails sent by 87 RCT participants to five counsellors during the course of a well-being enhancing CFT self-help intervention, to identify theoretically based compassionate attributes and skills. Next, in a quantitative analysis, we compared participants who did and did not show clinically relevant improvement on well-being with regard to the occurrence of compassionate attributes and skills.

RESULTS

Although the theoretical model of compassion integral to CFT was largely supported by the emails, it was slightly simplified so as to better fit the data. The adjusted model comprises five compassionate attributes (i.e., care for well-being, sensitivity, empathy, distress tolerance, and common humanity) and four compassionate skills (i.e., compassionate attention, reasoning, behaviour, and feeling/sensation). Three illustrative cases are presented to contribute to a better understanding of fundamental components of compassion. Quantitative analyses indicate that participants showing clinically relevant improvement on well-being expressed significantly more compassionate feeling/sensation compared to those who did not.

CONCLUSIONS

We found preliminary evidence for the conceptualization of compassion underlying CFT. Compassionate feeling/sensation bears particular interest when well-being is the intended outcome of CFT.

PRACTITIONER POINTS

Individuals participating in compassion-focused therapy for enhancing well-being experience a wide range of compassionate attributes and skills. Compassion-focused therapy may instigate well-being if a client is able to experience compassionate feeling/sensation.

Shame and guilt in the postnatal period: a systematic review

Objective: The aim of this review was to explore the unique contribution of shame (negative evaluation of the self) and guilt (negative evaluation of behaviour) to postnatal psychological symptoms. Background: Although shame and guilt are related to psychological symptoms, the separate effect of each in postnatal psychological symptoms are not yet known. Methods: Seven electronic databases were systematically reviewed for articles on: (1) quantitative measures of shame, guilt, and psychological symptoms (2) in the postnatal period for infants under two years of age (3) published in English. Results: Of the 1,615 articles retrieved using PRISMA guidelines, five met criteria and were analysed independently by two reviewers using the STROBE criteria. In mothers, shame was significantly related to stress and postnatal depression. Shame significantly predicted postnatal depression. Guilt was significantly related to postnatal depression; however, the relationship was substantially reduced when included with shame. In fathers, shame, but not guilt, was significantly related to stress, anxiety, and depression. Conclusion: Shame and guilt are trans-diagnostic phenomena, negatively impacting on postnatal psychological health, and potentially the parent-child relationship. More research is needed to develop awareness of the unique effects of shame and guilt to optimise perinatal intervention.

Cost-effectiveness of a mindfulness-based mental health promotion program: economic evaluation of a nonrandomized controlled trial with propensity score matching

BACKGROUND

Mental health promotion programs have been shown to reduce the burden associated with mental distress and prevent the onset of mental disorders, but evidence of cost-effectiveness is scarce.

OBJECTIVE

To evaluate the cost-effectiveness of a mindfulness-based mental health prevention program provided by health coaches in a multi-site field setting in Germany.

METHODS

The single-study based economic evaluation was conducted as part of a nonrandomized controlled trial, comparing the effects of a group-based prevention program to usual care based on propensity score matching. Participants (N = 1166) were recruited via a large statutory health insurance fund. Health outcome was assessed with the Hospital Anxiety and Depression Scale (HADS). Cost outcomes were actually incurred costs compiled from the health insurance' records. Incremental cost-effectiveness ratios (ICER) were analyzed from a societal and a health care perspective for a 12-month time horizon with sampling uncertainty being handled using nonparametric bootstrapping. A cost-effectiveness acceptability curve was graphed to determine the probability of cost-effectiveness at different willingness-to-pay ceiling ratios.

RESULTS

From a societal perspective, prevention was cost-effective compared to usual-care by providing larger effects of 1.97 units on the HADS (95% CI [1.14, 2.81], p < 0.001) at lower mean incremental total costs of €-57 (95% CI [- 634, 480], p = 0.84), yielding an ICER of €-29 (savings) per unit improvement. From a health care perspective, the incremental health benefits were achieved at additional direct costs of €181 for prevention participants (95% CI [40, 318], p = 0.01) with an ICER of €91 per unit improvement on the HADS. Willingness-to-pay for the prevention program to achieve a 95% probability of being cost-effective compared to usual-care, was estimated at €225 per unit improvement on the HADS score from a societal, and €191 from a health care perspective respectively. Sensitivity analyses suggested differential cost-effect-ratios depending on the initial distress of participants.

LIMITATIONS

Due to the complexity of the field trial, it was not feasible to randomize participants and offer an active control condition. This limitation was met by applying a rigorous matching procedure.

CONCLUSIONS

Our results indicate that universal mental health promotion programs in community settings might be a cost-effective strategy to enhance well-being. Differences between the societal and health care perspective underline the call for joint funding in the dissemination of preventive services.

TRIAL REGISTRATION

German Clinical Trials Registration ID: DRKS00006216 (2014/06/11, retrospective registration).

'She believed in me'. What patients with depression value in their relationship with practitioners. A secondary analysis of multiple qualitative data sets

BACKGROUND

Clinical guidance promotes the practitioner-patient relationship as integral to good quality person-centred care for patients with depression. However, patients can struggle to engage with practitioners and practitioners have indicated that they want more guidance on how to establish effective relationships with their patients.

OBJECTIVE

To identify what practitioner attributes patients with depression particularly value or find problematic.

METHOD

A secondary analysis of data collected during four qualitative studies, all of which entailed interviewing patients diagnosed with depression about their treatment experiences. Patients in the four studies had received different treatments. These included antidepressants, cognitive behaviour therapy, facilitated physical activity and listening visits. We thematically analysed 32 patient accounts.

RESULTS

We identified two complimentary sets of important practitioner attributes: the first based on the practitioner's bearing; the second based on the practitioner's enabling role. We found that patients value practitioners who consider their individual manner, share relevant personal information, show interest and acceptance, communicate clearly and listen carefully, collaborate on manageable goals and sanction greater patient self-care and self-compassion. It was also evident that patients receiving different treatments value the same practitioner attributes and that when these key practitioner qualities were not evident, patients were liable not to re-attend or comply with treatment.

CONCLUSION

The practitioner attributes that patients with depression most value have a positive impact on their engagement with treatment. Patients emphasise the importance of a practitioner's demeanour and encouragement, rather than the amount of time or specific treatment a practitioner is able to provide.

The neural mediators of kindness-based meditation: a theoretical model

Although kindness-based contemplative practices are increasingly employed by clinicians and cognitive researchers to enhance prosocial emotions, social cognitive skills, and well-being, and as a tool to understand the basic workings of the social mind, we lack a coherent theoretical model with which to test the mechanisms by which kindness-based meditation may alter the brain and body. Here, we link contemplative accounts of compassion and loving-kindness practices with research from social cognitive neuroscience and social psychology to generate predictions about how diverse practices may alter brain structure and function and related aspects of social cognition. Contingent on the nuances of the practice, kindness-based meditation may enhance the neural systems related to faster and more basic perceptual or motor simulation processes, simulation of another's affective body state, slower and higher-level perspective-taking, modulatory processes such as emotion regulation and self/other discrimination, and combinations thereof. This theoretical model will be discussed alongside best practices for testing such a model and potential implications and applications of future work.