Conceptual and design essentials for evaluating mechanisms of change

Brief online negative affect focused functional imagery training (FIT) improves four-week drinking outcomes in hazardous student drinkers: A pilot randomised controlled trial replication in South Africa

Background

Previous study has shown that functional imagery training (FIT) to utilise positive mental imagery in response to negative affect could improve alcohol-related outcomes. The current study aimed to replicate whether this negative affect focused FIT would improve alcohol-related outcomes in hazardous student drinkers in South Africa at four-week follow-up.

Methods

50 hazardous student drinkers who reported drinking to cope with negative affect were randomised into two groups. The active group (n = 25) was trained online over two weeks to respond to personalised negative drinking triggers by retrieving a personalised adaptive strategy they might use to mitigate negative affect, whereas the control group (n = 25) received standard risk information about binge drinking. Outcome measures including alcohol consumption, drinking motives, anxiety and depression, self-efficacy and use of protective behavioural strategies were obtained at baseline and four-week follow-up.

Results

FIT effects were revealed by three significant group-by-timepoint interactions in a per-protocol analysis: there was a significant decrease in depressive symptoms, drinking to cope and drinking for social reasons from baseline to follow-up in the active group, but not the control group. No effects were observed on alcohol consumption, self-efficacy, protective behaviour strategies and anxiety.

Conclusions

Preliminary evidence supports that online negative affect focused FIT can improve depression as well as coping and social drinking motives in South African hazardous student drinkers who drank to cope, at four-week follow-up, suggesting that the principles of this FIT approach might be adapted and incorporated into a clinical intervention to test for efficacy in mitigating substance use problems.

Mediators of change in psychological interventions for adult offenders with personality disorders: A scoping review of the literature

Offenders with personality disorder cause disproportionate harm to society and pose significant challenges for those responsible for their care and rehabilitation. Personality disorders are heterogeneous in terms of symptoms, as well as their pathways to offending behaviour. Thus, there is limited evidence regarding effective interventions. One solution might be to focus on how interventions are delivered as well as what is delivered. Within the non-offender personality disorder literature, the identification of potential mediators of change has enabled interventions to focus on 'how' they are delivered (e.g., therapeutic alliance) rather than the intervention itself. We explore the evidence and present a scoping review of the available literature on the mechanisms of change in psychological treatments for offenders with personality disorder. Only one study was found in the scoping review, highlighting a significant gap in the evidence base. We discuss the implications of this finding and potential future directions.

Mechanisms of cognitive behavioural therapy for insomnia

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

How effective psychological treatments work: mechanisms of change in cognitive behavioural therapy and beyond

BACKGROUND

Cognitive behavioural therapy (CBT) has, in the space of 50 years, evolved into the dominant modality in psychological therapy. Mechanism/s of change remain unclear, however.

AIMS

In this paper, we will describe key features of CBT that account for the pace of past and future developments, with a view to identifying candidates for mechanism of change. We also highlight the distinction between 'common elements' and 'mechanisms of change' in psychological treatment.

METHOD

The history of how behaviour therapy and cognitive therapy developed are considered, culminating in the wide range of strategies which now fall under the heading of cognitive behavioural therapy (CBT). We consider how the empirical grounding of CBT has led to the massive proliferation of effective treatment strategies. We then consider the relationship between 'common factors' and 'mechanisms of change', and propose that a particular type of psychological flexibility is the mechanism of change not only in CBT but also effective psychological therapies in general.

CONCLUSION

Good psychological therapies should ultimately involve supporting people experiencing psychological difficulties to understand where and how they have become 'stuck' in terms of factors involved in maintaining distress and impairment. A shared understanding is then evaluated and tested with the intention of empowering and enabling them to respond more flexibly and thereby reclaim their life.

Keepin' It REAL-Mantente REAL in Mexico: Longitudinal Examination of Youth Drug Resistance Strategies and Substance Use Among Early Adolescents

PURPOSE

This study examined if culturally and linguistically adapted versions of a US-developed adolescent substance use prevention intervention, keepin' it REAL (kiREAL), for Mexico increases the use of drug resistance strategies and if increased use of resistance strategies subsequently leads to a reduction in the frequency of substance use (i.e., alcohol, cigarette, marijuana, and inhalants).

METHODS

Students (N = 5,522, 49% female, age range = 11-17) in 36 middle schools across three cities in Mexico were randomized into three conditions: (1) Mantente REAL (MREAL), the culturally adapted version, (2) kiREAL-S, the linguistically adapted version, and (3) Control. Using survey data collected at four time points, random intercept cross-lagged path analyses tested the direct and indirect effects of MREAL and kiREAL-S compared to Control.

RESULTS

At time 2, the number of drug resistance strategies used by students increased in both MREAL (β = 0.103, p = .001) and kiREAL-S (β = 0.064, p = .002) compared to Control. However, only MREAL lead to less frequent use of alcohol (β = -0.001, p = .038), cigarettes (β = -0.001, p = .019), marijuana (β = -0.002, p = .030), and inhalants (β = -0.001, p = .021) at time 4, mediated through increased use of drug resistance strategies.

DISCUSSION

This study provides evidence that MREAL and kiREAL-S are successful in spurring use of the drug resistance strategies that are the core component of the intervention. Only MREAL achieved long-term effects on substance use behaviors, the ultimate objective of these interventions. These findings provide support for the value and importance of rigorous cultural adaptation of efficacious prevention programs as a necessary condition for enhancing prevention benefits for participating youth.

Building an Early Warning System for Depression: Rationale, Objectives, and Methods of the WARN-D Study

Background

Depression is common, debilitating, often chronic, and affects young people disproportionately. Given that only 50% of patients improve under initial treatment, experts agree that prevention is the most effective way to change depression's global disease burden. The biggest barrier to successful prevention is to identify individuals at risk for depression in the near future. To close this gap, this protocol paper introduces the WARN-D study, our effort to build a personalized early warning system for depression.

Method

To develop the system, we follow around 2,000 students over 2 years. Stage 1 comprises an extensive baseline assessment in which we collect a broad set of predictors for depression. Stage 2 lasts 3 months and zooms into participants' daily experiences that may predict depression; we use smartwatches to collect digital phenotype data such as sleep and activity, and we use a smartphone app to query participants about their experiences 4 times a day and once every Sunday. In Stage 3, we follow participants for 21 months, assessing transdiagnostic outcomes (including stress, functional impairment, anxiety, and depression) as well as additional predictors for future depression every 3 months. Collected data will be utilized to build a personalized prediction model for depression onset.

Discussion

Overall, WARN-D will function similarly to a weather forecast, with the core difference that one can only seek shelter from a thunderstorm and clean up afterwards, while depression may be successfully prevented before it occurs.

Addictions treatment mechanisms of change science and implementation science: A critical review

This manuscript aims to contribute to the next phase of mechanisms of behavior change (MOBC) science on alcohol or other drug use. Specifically, we encourage the transition from a basic science orientation (i.e., knowledge generation) to a translational science orientation (i.e., knowledge application or Translational MOBC Science). To inform that transition, we examine MOBC science and implementation science and consider how these two research areas can intersect to capitalize on the goals, strengths, and key methodologies of each. First, we define MOBC science and implementation science and offer a brief historical rationale for these two areas of clinical research. Second, we summarize similarities in rationale and discuss two scenarios where one draws from the other-MOBC science on implementation strategy outcomes and implementation science on MOBC. We then focus on the latter scenario, and briefly review the MOBC knowledge base to consider its readiness for knowledge translation. Finally, we provide a series of research recommendations to facilitate the translation of MOBC science. These recommendations include: (1) identifying and targeting MOBC that are well suited for implementation, (2) use of MOBC research results to inform broader health behavior change theory, and (3) triangulation of a more diverse set of research methodologies to build a translational MOBC knowledge base. Ultimately, it is important for gains borne from MOBC science to affect direct patient care, while basic MOBC research continues to be developed and refined over time. Potential implications of these developments include greater clinical significance for MOBC science, an efficient feedback loop between clinical research methodologies, a multi-level approach to understanding behavioral change, and reduced or eliminated siloes between MOBC science and implementation science.

Well-being impact assessment of artificial intelligence - A search for causality and proposal for an open platform for well-being impact assessment of AI systems

In recent years, the well-being impact assessment approach has been applied in the area of Artificial Intelligence (AI). Existing well-being frameworks and tools provide a relevant starting point. Taking into account its multidimensional nature, well-being assessment is well suited to assess both the expected positive effects of the technology as well as unintended negative consequences. To-date the establishment of causal links mostly stems from intuitive causal models. Such approaches neglect the fact that to prove causal links between the operation of an AI system and observed effects is difficult due to the immense complexity of the socio-technical context. This article aims at providing a framework for ascertaining the attribution of effects of observed impact of AI on well-being. An elaborated approach to impact assessment potentially enabling causal inferences is demonstrated. Furthermore, a new Open Platform for Well-Being Impact Assessment of AI systems (OPIA) is introduced, which is based on a distributed community to build reproducible evidence through effective identification, refinement, iterative testing, and cross-validation of expected causal structures.

Precision Implementation: An Approach to Mechanism Testing in Implementation Research

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.

Investigating active ingredients of the GenerationPMTO intervention: Predictors of postintervention change trajectories in parenting practices

Empirically determining the active ingredients of evidence-based parenting interventions is a promising means for strengthening interventions and enhancing their public health impact. This study aimed to determine which distinct ingredients of the GenerationPMTO (GenPMTO) intervention were associated with subsequent changes in parenting practices. Using a sample of 153 participants randomly assigned to the GenPMTO condition, we employed multilevel modeling to identify intervention ingredients empirically linked with change trajectories in parenting practices observed across the 2 years following intervention exposure. Coercive parenting and positive parenting outcomes were examined. Study results indicated that emotion regulation, effective communication, problem solving, and monitoring each demonstrated a significant pattern of findings for coercive parenting. Differential exposure to each of these ingredients significantly predicted the level of coercive parenting immediately postintervention and/or trajectories of change in coercive parenting across the subsequent 2-year period, controlling for coercive parenting at baseline. No significant predictors were found for positive parenting trajectories. Our findings suggest four components as active ingredients of the GenPMTO intervention for coercive parenting. Identification of these active ingredients may lead to strengthening future iterations of GenPMTO by expanding the set of core components specified in the model, which may further improve public health benefits. Implications for further understanding change stemming from evidence-based parenting interventions are also discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Estimating and Testing Causal Mediation Effects in Single-Case Experimental Designs Using State-Space Modeling

In this article, we present single-case causal mediation analysis as the application of causal mediation analysis to data collected within a single-case experiment. This method combines the focus on the individual with the focus on mechanisms of change, rendering it a promising approach for both mediation and single-case researchers. For this purpose, we propose a new method based on time-discrete state-space modeling to estimate the direct and indirect treatment effects. We demonstrate how to estimate the model for a single-case experiment on stress and craving in a routine alcohol consumer before and after an imposed period of abstinence. Furthermore, we present a simulation study that examines the estimation and testing of the standardized indirect effect. All parameters used to generate the data were recovered with acceptable precision. We use maximum likelihood and permutation procedures to calculate p-values and standard errors of the parameters estimates. The new method is promising for testing mediated effects in single-case experimental designs. We further discuss limitations of the new method with respect to causal inference, as well as more technical concerns, such as the choice of the time lags between the measurements.

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Empirical and Theoretical Framework, Intervention Design, and Study Protocol for a Randomized Controlled Trial

Background

Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment.

Objective

A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response.

Methods

The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk.

Results

Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022.

Conclusions

This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders.

Trial Registration

ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462

International Registered Report Identifier (IRRID)

DERR1-10.2196/30710

A Smartphone-Based Self-management Intervention for Individuals With Bipolar Disorder (LiveWell): Protocol Development for an Expert System to Provide Adaptive User Feedback

BACKGROUND

Bipolar disorder is a severe mental illness that results in significant morbidity and mortality. While pharmacotherapy is the primary treatment, adjunctive psychotherapy can improve outcomes. However, access to therapy is limited. Smartphones and other technologies can increase access to therapeutic strategies that enhance self-management while simultaneously augmenting care by providing adaptive delivery of content to users as well as alerts to providers to facilitate clinical care communication. Unfortunately, while adaptive interventions are being developed and tested to improve care, information describing the components of adaptive interventions is often not published in sufficient detail to facilitate replication and improvement of these interventions.

OBJECTIVE

To contribute to and support the improvement and dissemination of technology-based mental health interventions, we provide a detailed description of the expert system for adaptively delivering content and facilitating clinical care communication for LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder.

METHODS

Information from empirically supported psychotherapies for bipolar disorder, health psychology behavior change theories, and chronic disease self-management models was combined with user-centered design data and psychiatrist feedback to guide the development of the expert system.

RESULTS

Decision points determining the timing of intervention option adaptation were selected to occur daily and weekly based on self-report data for medication adherence, sleep duration, routine, and wellness levels. These data were selected for use as the tailoring variables determining which intervention options to deliver when and to whom. Decision rules linking delivery of options and tailoring variable thresholds were developed based on existing literature regarding bipolar disorder clinical status and psychiatrist feedback. To address the need for treatment adaptation with varying clinical statuses, decision rules for a clinical status state machine were developed using self-reported wellness rating data. Clinical status from this state machine was incorporated into hierarchal decision tables that select content for delivery to users and alerts to providers. The majority of the adaptive content addresses sleep duration, medication adherence, managing signs and symptoms, building and utilizing support, and keeping a regular routine, as well as determinants underlying engagement in these target behaviors as follows: attitudes and perceptions, knowledge, support, evaluation, and planning. However, when problems with early warning signs, symptoms, and transitions to more acute clinical states are detected, the decision rules shift the adaptive content to focus on managing signs and symptoms, and engaging with psychiatric providers.

CONCLUSIONS

Adaptive mental health technologies have the potential to enhance the self-management of mental health disorders. The need for individuals with bipolar disorder to engage in the management of multiple target behaviors and to address changes in clinical status highlights the importance of detailed reporting of adaptive intervention components to allow replication and improvement of adaptive mental health technologies for complex mental health problems.

The Role of Acceptance and Change in Recovery from Substance Use Disorders

Long-term recovery (LTR) from substance use disorders (SUDs) has been described as a complex process. It has been proposed that psychological mechanisms can influence the resolution of problematic substance using behaviors and may explain how and why a recovery process works. The aims of this narrative review were to (a) examine acceptance and change as an underlying mechanism in LTR from SUDs; (b) examine the practice of acceptance and change in the Narcotics Anonymous (NA) and Alcoholics Anonymous (AA) programs; and (c) present a conceptual model of self-acceptance and change in LTR from SUDs. Based on dialectical behavioral philosophy and mindfulness-based intervention, I posited that self-acceptance is an underlying mechanism that addresses the cyclical nature of shame, guilt, and SUDs; improves emotion dysregulation; psychological well-being; and activates a change process of recovery from SUDs. This article contributes to the field by presenting the opposing forces of acceptance versus change and their synthesis in promoting LTR from SUDs, and by discussing the practice of acceptance and change in the AA and NA programs.

From Therapeutic Factors to Mechanisms of Change in the Creative Arts Therapies: A Scoping Review

Empirical studies in the creative arts therapies (CATs; i.e., art therapy, dance/movement therapy, drama therapy, music therapy, psychodrama, and poetry/bibliotherapy) have grown rapidly in the last 10 years, documenting their positive impact on a wide range of psychological and physiological outcomes (e.g., stress, trauma, depression, anxiety, and pain). However, it remains unclear how and why the CATs have positive effects, and which therapeutic factors account for these changes. Research that specifically focuses on the therapeutic factors and/or mechanisms of change in CATs is only beginning to emerge. To gain more insight into how and why the CATs influence outcomes, we conducted a scoping review (N_studies = 67) to pinpoint therapeutic factors specific to each CATs discipline, joint factors of CATs, and more generic common factors across all psychotherapy approaches. This review therefore provides an overview of empirical CATs studies dealing with therapeutic factors and/or mechanisms of change, and a detailed analysis of these therapeutic factors which are grouped into domains. A framework of 19 domains of CATs therapeutic factors is proposed, of which the three domains are composed solely of factors unique to the CATs: “embodiment,” “concretization,” and “symbolism and metaphors.” The terminology used in change process research is clarified, and the implications for future research, clinical practice, and CATs education are discussed.

Active Ingredients and Mechanisms of Change in Motivational Interviewing for Smoking Cessation in Patients With Coronary Artery Disease: A Mixed Methods Study

Background: For patients with coronary artery disease (CAD), smoking is an important risk factor for the recurrence of a cardiovascular event. Motivational interviewing (MI) may increase the motivation of the smokers to stop smoking. Data on MI for smoking cessation in patients with CAD are limited, and the active ingredients and working mechanisms of MI in smoking cessation are largely unknown. Therefore, this study was designed to explore active ingredients and working mechanisms of MI for smoking cessation in smokers with CAD, shortly after a cardiovascular event.

Methods: We conducted a qualitative multiple case study of 24 patients with CAD who participated in a randomized trial on lifestyle change. One hundred and nine audio-recorded MI sessions were coded with a combination of the sequential code for observing process exchanges (SCOPE) and the motivational interviewing skill code (MISC). The analysis of the cases consisted of three phases: single case analysis, cross-case analysis, and cross-case synthesis. In a quantitative sequential analysis, we calculated the transition probabilities between the use of MI techniques by the coaches and the subsequent patient statements concerning smoking cessation.

Results: In 12 cases, we observed ingredients that appeared to activate the mechanisms of change. Active ingredients were compositions of behaviors of the coaches (e.g., supporting self-efficacy and supporting autonomy) and patient reactions (e.g., in-depth self-exploration and change talk), interacting over large parts of an MI session. The composition of active ingredients differed among cases, as the patient process and the MI-coaching strategy differed. Particularly, change talk and self-efficacy appeared to stimulate the mechanisms of change “arguing oneself into change” and “increasing self-efficacy/confidence.”

Conclusion: Harnessing active ingredients that target the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” is a good MI strategy for smoking cessation, because it addresses the ambivalence of a patient toward his/her ability to quit, while, after the actual cessation, maintaining the feeling of urgency to persist in not smoking in the patient.

The role of expressive suppression and cognitive reappraisal in cognitive behavioral therapy for social anxiety disorder: A study of self-report, subjective, and electrocortical measures

BACKGROUND

Contemporary models of cognitive behavioral therapy (CBT) for social anxiety disorder (SAD) emphasize emotion dysregulation as a core impairment whose reduction may play a causal role in psychotherapy. The current study examined changes in use of emotion regulation strategies as possible mechanisms of change in CBT for SAD. Specifically, we examined changes in expressive suppression and cognitive reappraisal during CBT and whether these changes predict treatment outcome.

METHODS

Patients (n = 34; 13 females; Mean age = 28.36 (6.97)) were allocated to 16-20 sessions of CBT. An electrocortical measure of emotion regulation and a clinician-rated measure of SAD were administered monthly. Self-report measures of emotion regulation and social anxiety were administered weekly. Multilevel models were used to examine changes in emotion regulation during treatment and cross-lagged associations between emotion regulation and anxiety.

RESULTS

CBT led to decreased suppression frequency, increased reappraisal self-efficacy, and decreased unpleasantness for SAD-related pictures (ps < .05). At post-treatment, patients were equivalent to healthy controls in terms of suppression frequency and subjective reactivity to SAD-related stimuli. Gains were maintained at 3-months follow-up. Decreases in suppression frequency and electrocortical reactivity to SAD-related pictures predicted lower subsequent anxiety but not the other way around (ps < .05). Lower anxiety predicted greater subsequent increases in reappraisal self-efficacy.

LIMITATIONS

The lack of a control group precludes conclusions regarding mechanisms specificity.

CONCLUSIONS

Decreased frequency of suppression is a potential mechanism of change in CBT for SAD.

Therapeutic change mechanisms in adults with medically unexplained physical symptoms: A systematic review

OBJECTIVE

Although psychological treatments for patients suffering from medically unexplained physical symptoms (MUPS) show promising results, evidence for their effectiveness is still limited. The aim of this study was to review the existing empirical support for change mechanisms that explain treatment effect in terms of symptom intensity and symptom interference in the daily lives of patients.

METHODS

A systematic database search was conducted. Sixty-seven eligible studies were found, and change mechanism effects were extracted from them. The data were subjected to a systematic review.

RESULTS

Fifteen change mechanisms were identified. Those receiving the most consistent support included Increasing symptom acceptance, Development of coping strategies, and Positive treatment expectations, although the last mechanism was investigated in only two studies. Almost all mechanisms received support for at least one type of outcome, either at post-treatment or at follow-up.

CONCLUSIONS

Although some empirical support exists for many mechanisms, some of them have received only marginal attention in empirical studies. These limitations prevented us from deriving more definite conclusions.

A More Efficient Causal Mediator Model Without the No-Unmeasured-Confounder Assumption

Mediator models have been developed primarily under the assumption of no-unmeasured-confounding. In many situations, this assumption is violated and may lead to the identification of mediator variables that actually are statistical artifacts. The rank preserving model (RPM) is an alternative approach to estimate controlled direct and mediator effects. It is based on the structural mean models framework and a no-effect-modifier assumption. The RPM assumes that unobserved confounders do not interact with treatment or mediators. This assumption is often more plausible to hold than the no-unmeasured-confounder assumption. So far, models using the no-effect-modifier assumption have been rarely used, which might be due to its low power and inefficiency in many scenarios. Here, a semi-parametric nonlinear extension, the nRPM, is proposed that overcomes this inefficiency using thin plate regression splines that both increase the predictive power of the model and decrease the misspecification present in many situations. In a simulation study, it is shown that the nRPM provides estimates that are robust against the violation of the no-effect-modifier assumption and that are substantively more efficient than those of the RPM. The model is illustrated using a data set on CD4 cell counts in a context of the human immunodeficiency virus (HIV).

Mechanisms of change in female-specific and gender-neutral cognitive behavioral therapy for women with alcohol use disorder

OBJECTIVE

In a randomized trial for women with alcohol use disorders (AUD), the efficacy of Female-Specific Cognitive Behavioral Therapy (FS-CBT) was compared with Gender-Neutral CBT (GN-CBT; Epstein et al., 2018). The current study examined whether putative mechanisms of change differed between treatment conditions, using a novel statistical approach. Both treatments were hypothesized to work by increasing use of alcohol-related coping skills (coping) and confidence to abstain from drinking (confidence), but FS-CBT additionally targeted female-salient mechanisms: anxiety, depression, sociotropy (i.e., overinvestment in others' opinion of oneself), autonomy, and social networks supportive of abstinence.

METHOD

Ninety-nine women with AUD (55 in GN-CBT, 44 in FS-CBT) completed self-report assessments at baseline and 0, 6, and 12 months posttreatment. Multilevel vector autoregression estimation was used to analyze associations between putative mechanisms of change, and network models of those associations were generated using network analysis.

RESULTS

Across conditions, higher confidence and coping were directly associated with less drinking; autonomy was directly and indirectly associated with drinking. Additionally, network analysis indicated that although variation in depression was associated with change in other variables specifically for GN-CBT, sociotropy was associated with change specifically in FS-CBT.

CONCLUSIONS

Women receiving CBT-AUD changed their drinking through increased confidence to abstain and greater use of coping skills. Autonomy played a central role in behavior change across treatment conditions. Participants receiving treatment tailored to women also changed through decreases in sociotropy and increases in social support for abstinence. For women who received standard CBT, changes in depression were important to clinical improvement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Beyond linear mediation: Toward a dynamic network approach to study treatment processes

Few clinical scientists would disagree that more research is needed on the underlying mechanisms and processes of change in psychological therapies. In the dominant current approach, processes of change are studied through mediation. The study of mediation has been largely structured around a distinction between moderation and mediation first popularized by Baron and Kenny's (1986) seminal article, which is based on a nomothetic and cross-sectional framework. In this article, we argue that this approach is unable to adequately address change processes in psychological therapies, because it falsely assumes that treatment change is a linear, unidirectional, pauci-variate process and that the statistical assumptions are met to study processes of change in an individual using a nomothetic approach. In contrast, we propose that treatment is a dynamic process involving numerous variables that may form bi-directional and complex relationships that differ between individuals. Such relationships can best be studied using an individual dynamic network approach connected to nomothetic generalization methods that are based on a firm idiographic foundation. We argue that our proposal is available, viable, and can readily be integrated into existing research strategies. We further argue that adopting an individual dynamic network approach combined with experimental analyses will accelerate the study of treatment change processes, which is necessary as the field of evidence-based care moves toward a process-based model. We encourage future research to gather empirical evidence to examine this approach.

Active Ingredients and Mechanisms of Change in Motivational Interviewing for Medication Adherence. A Mixed Methods Study of Patient-Therapist Interaction in Patients With Schizophrenia

BACKGROUND

Trials studying Motivational Interviewing (MI) to improve medication adherence in patients with schizophrenia showed mixed results. Moreover, it is unknown which active MI-ingredients are associated with mechanisms of change in patients with schizophrenia. To enhance the effect of MI for patients with schizophrenia, we studied MI's active ingredients and its working mechanisms.

METHODS

First, based on MI literature, we developed a model of potential active ingredients and mechanisms of change of MI in patients with schizophrenia. We used this model in a qualitative multiple case study to analyze the application of the active ingredients and the occurrence of mechanisms of change. We studied the cases of fourteen patients with schizophrenia who participated in a study on the effect of MI on medication adherence. Second, we used the Generalized Sequential Querier (GSEQ 5.1) to perform a sequential analysis of the MI-conversations aiming to assess the transitional probabilities between therapist use of MI-techniques and subsequent patient reactions in terms of change talk and sustain talk.

RESULTS

We found the therapist factor "a trusting relationship and empathy" important to enable sufficient depth in the conversation to allow for the opportunity of triggering mechanisms of change. The most important conversational techniques we observed that shape the hypothesized active ingredients are reflections and questions addressing medication adherent behavior or intentions, which approximately 70% of the time was followed by "patient change talk". Surprisingly, sequential MI-consistent therapist behavior like "affirmation" and "emphasizing control" was only about 6% of the time followed by patient change talk. If the active ingredients were embedded in more comprehensive MI-strategies they had more impact on the mechanisms of change.

CONCLUSIONS

Mechanisms of change mostly occurred after an interaction of active ingredients contributed by both therapist and patient. Our model of active ingredients and mechanisms of change enabled us to see "MI at work" in the MI-sessions under study, and this model may help practitioners to shape their MI-strategies to a potentially more effective MI.

Effects of craving on opioid use are attenuated after pain coping counseling in adults with chronic pain and prescription opioid addiction

OBJECTIVE

Risk for prescription opioid addiction is an endemic public health concern, especially for adults with chronic pain. This study examined craving as a mediator from pain to opioid use outcomes during prescription opioid addiction treatment and tested whether counseling in pain coping skills moderated the effects of craving on treatment outcomes.

METHOD

Secondary analysis on a sample (N = 148) randomized to standard or enhanced counseling for 12 weeks with adjunct opioid maintenance medication. Multilevel analyses examined mediated effects between weekly pain, craving, and opioid use, and tested the interaction between craving and a counseling module on pain coping skills.

RESULTS

Greater pain predicted greater craving (β = 0.25, p < .001), which predicted next-week opioid use (β = 0.17, p < .001). A statistically significant indirect effect of craving (β = 0.04, 95% CI [0.02, 0.06]) mediated 95% of the total effect from pain to opioid use. A significant interaction (b = -0.22, p < .01) revealed that after receiving the pain coping module, the association between craving and next-week opioid use was reduced, with greater exposure to the module associated with stronger effects (b = -0.12, p < .01).

CONCLUSION

More severe pain predicts greater opioid use due to the association between pain and cravings. Pain coping skills counseling suppressed the association between cravings and opioid use. For adults with chronic pain receiving treatment for prescription opioid addiction, interventions that address cravings through behavioral pain coping skills may be crucial for achieving optimal treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Descriptive Norms but not Harm Reduction Strategies as a Mediator of Personalized Boosters After a Computerized College Drinking Intervention

BACKGROUND

Computer-delivered programs to reduce college drinking have strong appeal but are sometimes less efficacious than their in-person counterparts. Boosters may be an ideal way to strengthen and extend the effects of computerized interventions while maintaining low cost and easy dissemination. However, little is known about how they work. Consequently, the current study aimed to explore descriptive perceived drinking norms and use of protective behavioral strategies (PBS) as potential mediators of booster effects. We also examined norms and PBS as mediators of the main intervention. The present study was a follow-up analysis of data from a randomized controlled trial (Alcohol Clin Exp Res 42, 2018, 1735) testing the efficacy of emailed boosters containing personalized feedback after a computerized alcohol intervention.

METHODS

Participants were 537 (67.4% women) emerging adult college drinkers (M age = 19.65, SD = 1.67). They were randomly assigned to one of 3 conditions: general health education, alcohol intervention only, or alcohol intervention plus booster email. Participants completed assessments at baseline and follow-ups through 9 months.

RESULTS

Descriptive norms were a mediator of booster efficacy where receiving the booster yielded stronger reductions in alcohol use through reduced concurrent norms; however, fully longitudinal models did not reach significance. There was also an indirect effect for the intervention where those who received the intervention experienced an increase in drinking through increased concurrent norms. However, a stronger direct effect was found where those who received the intervention experienced a stronger decrease in drinking after controlling for norms. There was no support for PBS as a mediator of booster or intervention efficacy.

CONCLUSIONS

The present study was the first, to our knowledge, to demonstrate a potential mechanism of change in booster interventions. A simple, succinct reminder via email led to reductions in perceptions of how much peers drink, and this led to reductions in alcohol consumption. Our findings support the promise of utilizing brief and easily implemented targeted messaging to enhance the potency of computerized interventions for college drinkers.

A test of the feasibility of a visualization method to show the depth and duration of awareness during Method of Levels therapy

Many psychological therapies help clients to direct and sustain their awareness onto specific aspects of their problems to promote change. Yet, no theory-driven measure exists that can code moment-by-moment changes in awareness during a therapy session. It is known that awareness plays a crucial role in the process of change, but little is known about the underlying core processes. Perceptual Control Theory (PCT) offers a scientific explanation of psychological distress as loss of control and describes the role of awareness in processes responsible for restoring control by resolving any internal conflict. The Depth and Duration of Awareness Coding Scheme (D-DACS) was previously developed to capture the person’s current focus of awareness and its duration on the areas that from a PCT point of view are desirable in order to facilitate effective psychological change. The current research applies D-DACS to code three publicly available Method of Levels (MOL) therapy sessions delivered by an expert therapist and presents a visual representation of the client’s presumed attention in these sessions. The results showed that an average of 61.65% of the client’s attention was focused on the D-DACS areas, which is higher than the previous studies involving novel therapists. The produced visual representation of the clients’ presumed attention helps to examine the utility of this new coding scheme and further examine the validity of the underlying theory. Such work might help in examining effectiveness of therapy in meeting the underlying theoretical foundations of change. However, limitations and areas for improvement are also evident.

Key learning aims

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Understanding Therapeutic Change Process Research Through Multilevel Modeling and Text Mining

Online interventions hold great potential for Therapeutic Change Process Research (TCPR), a field that aims to relate in-therapeutic change processes to the outcomes of interventions. Online a client is treated essentially through the language their counsellor uses, therefore the verbal interaction contains many important ingredients that bring about change. TCPR faces two challenges: how to derive meaningful change processes from texts, and secondly, how to assess these complex, varied, and multi-layered processes? We advocate the use text mining and multi-level models (MLMs): the former offers tools and methods to discovers patterns in texts; the latter can analyse these change processes as outcomes that vary at multiple levels. We (re-)used the data from Lamers et al. (2015) because it includes outcomes and the complete online intervention for clients with mild depressive symptoms. We used text mining to obtain basic text-variables from e-mails, that we analyzed through MLMs. We found that we could relate outcomes of interventions to variables containing text-information. We conclude that we can indeed bridge text mining and MLMs for TCPR as it was possible to relate text-information (obtained through text mining) to multi-leveled TCPR outcomes (using a MLM). Text mining can be helpful to obtain change processes, which is also the main challenge for TCPR. We showed how MLMs and text mining can be combined, but our proposition leaves open how to obtain the most relevant textual operationalization of TCPR concepts. That requires interdisciplinary collaboration and discussion. The future does look bright: based on our proof-of-concept study we conclude that MLMs and text mining can indeed advance TCPR.

Self-Efficacy to Limit Drinking Mediates the Association between Attitudes and Alcohol-Related Outcomes

Personal attitudes toward alcohol consumption are reliable predictors of alcohol use and related problems, with emerging work suggesting that one's favorable attitude toward limited drinking (i.e., at levels below the threshold for heavy episodic drinking) is a buffer against alcohol use and binge drinking. However, little work has examined the specific mechanism(s) through which one's personal attitude toward limited drinking is associated with alcohol use and related problems. One such mechanism may be an individual's self-efficacy to limit their alcohol use. The current study aimed to evaluate whether self-efficacy to limit one's alcohol use mediates the association between one's personal attitude toward limited drinking and actual alcohol use and related problems over time. Participants were mandated students (n = 568; 28% female) who violated campus alcohol policy and received a brief motivational intervention. Mediation models were used to test (a) self-efficacy to limit one's alcohol use as a traditional mediator of the attitudes-drinking quantity association and (b) self-efficacy and drinking quantity as serial mediators of the attitudes-alcohol-problems link. Favorable attitudes toward limiting drinking at baseline were positively associated with self-efficacy to limit drinking at 1 month, which was associated with a reduction in drinking quantity at 3 months; this, in turn, was associated with a reduction in alcohol-related problems at 5 months. These findings provide a rationale for incorporating attitudes and self-efficacy in the development and refinement of intervention strategies.

The Future of Intervention Science: Process-Based Therapy

Clinical science seems to have reached a tipping point. It appears that a new paradigm is beginning to emerge that is questioning the validity and utility of the medical illness model, which assumes that latent disease entities are targeted with specific therapy protocols. A new generation of evidence-based care has begun to move toward process-based therapies to target core mediators and moderators based on testable theories. This could represent a paradigm shift in clinical science with far-reaching implications. Clinical science might see a decline of named therapies defined by set technologies, a decline of broad schools, a rise of testable models, a rise of mediation and moderation studies, the emergence of new forms of diagnosis based on functional analysis, a move from nomothetic to idiographic approaches, and a move toward processes that specify modifiable elements. These changes could integrate or bridge different treatment orientations, settings, and even cultures.

Profiles of behavior change constructs for reducing alcohol use in women at risk of an alcohol-exposed pregnancy

Using data from Project CHOICES, a randomized controlled trial to test an intervention to prevent alcohol-exposed pregnancies, this study examined process of change profiles composed of Transtheoretical Model of Change (TTM) constructs for alcohol. The primary purpose was to identify a profile of TTM variables associated with reduced drinking. Participants (n = 570) were women at risk of an alcohol-exposed pregnancy recruited from high risk settings. Profile analyses compared end-of-treatment (i.e., 3 months postintake) TTM construct mean profiles for women who reduced drinking to below NIAAA-defined risk levels1 (changers) with women who continued to drink at risk levels (nonchangers) at the 9-month follow-up. TTM construct profiles included experiential and behavioral processes of change, pros and cons for change, confidence to reduce drinking, and temptation to drink above risk levels. Results revealed a parallelism effect or interaction (p < .001) in the end-of-treatment TTM construct profiles for the changers versus the nonchangers at the 9-month follow-up. Changers reported greater pros (p < .001) and lower cons for change (p = .012), greater confidence (p = .030), lower temptation (p < .001) and greater use of the experiential (p < .001) and behavioral processes of change (p < .001). A larger percentage of the women from the CHOICES intervention were in the end-of-treatment profile of the changers (48%) compared with the control condition (39%; p = .042). Interventions can potentially be enhanced by clinicians' understanding what successful change "looks like" for specific clients in terms of their process use, decisional balance, and self-efficacy, allowing for tailored interventions targeted to each client's specific strengths and deficits. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The role of the individual in the coming era of process-based therapy

For decades the development of evidence-based therapy has been based on experimental tests of protocols designed to impact psychiatric syndromes. As this paradigm weakens, a more process-based therapy approach is rising in its place, focused on how to best target and change core biopsychosocial processes in specific situations for given goals with given clients. This is an inherently more idiographic question than has normally been at issue in evidence-based therapy over the last few decades. In this article we explore methods of assessment and analysis that can integrate idiographic and nomothetic approaches in a process-based era.

Mediators and Moderators of a Personalized Feedback Alcohol Intervention for Nonstudent Emerging Adult Drinkers

BACKGROUND

The main objective of this study was to test proposed mediators and moderators of a personalized feedback alcohol intervention (PFI) on alcohol use. Data for the current investigation came from an earlier randomized controlled trial of a PFI targeted for nonstudent heavy drinkers between 18 and 25 years.

METHODS

Participants were 164 (65.9% men) drinkers recruited from the community. They were randomly assigned to either a single-session PFI or an assessment-only (AO) control group. Follow-up assessments at 1 and 3 months were included for analysis.

RESULTS

Perceived drinking norms mediated the intervention effect on quantity, frequency, and peak drinking; 2 dimensions of protective behavioral strategies (PBS) mediated the intervention effect on peak drinking; and drinking to cope motives did not mediate any drinking outcomes. Of the moderating factors examined (i.e., norms, PBS, drink to cope motives, age, gender), only PBS related to serious harm reduction moderated intervention impact. Specifically, for those high in serious harm reduction PBS at baseline, postintervention reductions in drinking were stronger for the PFI group compared to AO.

CONCLUSIONS

Overall, findings highlight the importance of correcting misperceived drinking norms and addressing the use of specific PBS in brief interventions. The knowledge gained from this study represents an important step toward minimizing drinking-related harms that are disproportionately experienced by those with lower educational attainment.

Reasons for Testing Mediation in the Absence of an Intervention Effect: A Research Imperative in Prevention and Intervention Research

OBJECTIVE

Mediation models are used in prevention and intervention research to assess the mechanisms by which interventions influence outcomes. However, researchers may not investigate mediators in the absence of intervention effects on the primary outcome variable. There is emerging evidence that in some situations, tests of mediated effects can be statistically significant when the total intervention effect is not statistically significant. In addition, there are important conceptual and practical reasons for investigating mediation when the intervention effect is nonsignificant.

METHOD

This article discusses the conditions under which mediation may be present when an intervention effect does not have a statistically significant effect and why mediation should always be considered important.

RESULTS

Mediation may be present in the following conditions: when the total and mediated effects are equal in value, when the mediated and direct effects have opposing signs, when mediated effects are equal across single and multiple-mediator models, and when specific mediated effects have opposing signs. Mediation should be conducted in every study because it provides the opportunity to test known and replicable mediators, to use mediators as an intervention manipulation check, and to address action and conceptual theory in intervention models.

CONCLUSIONS

Mediators are central to intervention programs, and mediators should be investigated for the valuable information they provide about the success or failure of interventions.

A text message intervention to reduce 21st birthday alcohol consumption: Evaluation of a two-group randomized controlled trial

Twenty-first birthdays are associated with extreme levels of heavy drinking and alcohol-related harm. Effective preventive interventions that are acceptable to young adults are needed. The current study tested the efficacy of a brief text-message intervention for reducing 21st birthday alcohol involvement designed to correct perceived 21st birthday drinking norms and provide protective behavioral strategies (PBS). We also examined potential moderators and mediators. College students (n = 200) with an upcoming 21st birthday completed a baseline assessment and were randomized to a text-message intervention or an assessment-only control condition. For participants in the intervention group, Message 1 (sent one day before the birthday celebration) focused on personalized normative feedback, and Message 2 (sent day of the birthday celebration) discussed PBS to minimize risk. Primary outcomes were assessed using responses to a follow-up assessment the day after their birthday celebration (93% completion rate). Zero-inflated negative binomial regression analyses did not reveal an overall intervention effect for estimated Blood Alcohol Content (eBAC) or alcohol problems on the 21st birthday celebration. In partial support of our hypothesis, there was an indirect effect of perceived 21st birthday norms on 21st birthday eBAC. The intervention was associated with reduced perceived norms, which was, in turn, related to a lower eBAC. There was a 3-way interaction between drinks per week, anticipated eBAC, and intervention condition for the count portion of actual eBAC such that the intervention reduced eBAC among a high-risk subset of the sample. Future research may benefit from further refining the personalized normative feedback (PNF) component of 21st birthday interventions. (PsycINFO Database Record

Moderators of sudden gains after sessions addressing emotion regulation among women in treatment for alcohol use

Sudden gains (SGs) are defined as abrupt and significant improvements in mental health symptoms that occur between two psychotherapy sessions. Preliminary evidence suggests that SGs may be an important pattern of symptom reduction in the treatment of alcohol use disorder (AUD) (i.e., a steep between-session reduction in drinking or alcohol craving frequency or intensity) (Drapkin, Epstein, McCrady, & Eddie, 2015). The current study examined SGs within two randomized clinical trials (RCTs) testing female-specific cognitive behavior therapy (CBT) protocol for AUD (n=146). We tested a priori hypotheses about whether women's baseline depression, anxiety, and confidence to be abstinent while in a negative emotional state would predict attainment of SGs after attending sessions that addressed depression, anxiety, and emotion regulation (i.e., sessions five and six of the 12-session protocol). Data were collected at baseline, within treatment, and 15months after baseline. Results showed that women with high levels of depression and/or anxiety and low confidence to be abstinent in a negative emotional state at baseline were more likely to experience a SG (steep decrease in drinking) after sessions five and six (p=0.02). Further, among women with high levels of depression and/or anxiety at baseline, those who experienced both a SG in drinking after session five/six and had higher confidence to remain abstinent in a negative emotional state at the end of treatment reported lower drinking frequency at 9- but not 15-month follow-up [95% CI=(-2.65, -0.86)]. Findings support the value of providing interventions targeting mood and emotion regulation in AUD treatment for women.

Does improvement in maternal attachment representations predict greater maternal sensitivity, child attachment security and lower rates of relapse to substance use? A second test of Mothering from the Inside Out treatment mechanisms

In this study, we replicated a rigorous test of the proposed mechanisms of change associated with Mothering from the Inside out (MIO), an evidence-based parenting therapy that aims to enhance maternal reflective functioning and mental representations of caregiving in mothers enrolled in addiction treatment and caring for young children. First, using data from 84 mothers who enrolled in our second randomized controlled trial, we examined whether therapist fidelity to core MIO treatment components predicted improvement in maternal reflective functioning and mental representations of caregiving, even after taking fidelity to non-MIO components into account. Next, we examined whether improvement in directly targeted outcomes (e.g., maternal mentalizing and mental representations of caregiving) led to improvements in the indirectly targeted outcome of maternal caregiving sensitivity, even after controlling for other plausible competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Third, we examined whether improvement in targeted parenting outcomes (e.g., maternal mentalizing, mental representations of caregiving and caregiving sensitivity) was associated in improvement in child attachment status, even after controlling for competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Finally, we examined whether improvement in maternal mentalizing and caregiving representations was associated with a reduction in relapse to substance use. Support was found for the first three tests of mechanisms but not the fourth. Implications for future research and intervention development are discussed.

Event-Related Potentials as Biomarkers of Behavior Change Mechanisms in Substance Use Disorder Treatment

Substance use disorders (SUDs) are one of the most prevalent psychiatric conditions and represent a significant public health concern. Substantial research has identified key processes related to reinforcement and cognition for the development and maintenance of SUDs, and these processes represent viable treatment targets for psychosocial and pharmacological interventions. Research on SUD treatments has suggested that most approaches are comparable in effectiveness. As a result, recent work has focused on delineating the underlying mechanisms of behavior change that drive SUD treatment outcome. Given the rapid fluctuations associated with the key neurocognitive processes associated with SUDs, high-temporal-resolution measures of human brain processing, namely event-related potentials (ERPs), are uniquely suited to expand our understanding of the underlying neural mechanisms of change during and after SUD treatment. The value of ERPs in the context of SUD treatment are discussed along with work demonstrating the predictive validity of ERPs as biomarkers of SUD treatment response. Example associations between multiple ERP components and psychosocial and/or pharmacological treatment outcome include the P3a and P3b (in response to neutral and substance-related cues), the attention-related negativities (e.g., N170, N200), the late positive potential, and the error-related negativity. Also addressed are limitations of the biomarker approach to underscore the need for research programs evaluating mechanisms of change. Finally, we emphasize the advantages of ERPs as indices of behavior change in SUD treatment and outline issues relevant for future directions in this context.

Effect of computerized cognitive behavioral therapy on acquisition of coping skills among cocaine-dependent individuals enrolled in methadone maintenance

The acquisition of coping skills has long been considered one of the putative mechanisms of cognitive behavioral therapy (CBT) for substance use disorders, yet consistent statistical support is lacking. This study sought to replicate and extend prior findings regarding the quality of coping skills as a mediator of abstinence outcomes from a computerized CBT program for substance users. Participants were methadone-maintained, cocaine dependent individuals enrolled in a clinical trial evaluating the efficacy of computer-based training for CBT ('CBT4CBT') as an add-on to treatment as usual (TAU+CBT4CBT) compared to TAU only. A subsample (N=71) completed a role play assessment to measure coping skills, the Drug Risk Response Test (DRRT), which was administered before, during (week 4), and after the 8-week treatment period. Participants' verbal responses to various high-risk situations for cocaine use were recorded and independent evaluators rated the quality of the coping responses. Results of repeated measures analyses revealed a main effect of time for the quality of overall responses [F(1, 141.26)=4.29, p<0.01], indicating improvement in the quality of coping skills across groups, yet no differential effect of treatment. Despite the significant association between coping responses and abstinence outcomes, analyses did not support the quality of coping skills as a mediator of treatment effects. However, among the high-risk situations wherein individuals provided lower quality responses at baseline, those assigned to TAU+CBT4CBT showed greater improvement compared to those assigned to TAU only [F(1, 697.65)=6.47, p=0.01].

CONCLUSIONS

This study failed to replicate the quality of coping skills as a mediator of CBT4CBT's effect on reducing drug use previously shown in a mixed outpatient substance use sample. However, in this methadone maintained sample, those with poorer quality skills in response to certain high-risk situations at baseline appeared to improve their coping strategies following CBT4CBT compared to standard methadone treatment alone.

A randomized controlled trial of a web-based, personalized normative feedback alcohol intervention for young-adult veterans

OBJECTIVE

Young-adult American veterans are at risk for problematic alcohol use. However, they are unlikely to seek care and may drop out from lengthy, multicomponent treatments when they do get care. This randomized controlled trial tested a very brief alcohol intervention delivered over the Internet to reach the population of young-adult veterans to help reduce their drinking.

METHOD

Veterans (N = 784) were recruited from Facebook and randomized to either a control condition or a personalized normative feedback (PNF) intervention seeking to correct drinking perceptions of gender-specific veteran peers.

RESULTS

At immediate postintervention, PNF participants reported greater reductions in their perceptions of peer drinking and intentions to drink over the next month, compared with control participants. At 1-month follow-up, PNF participants reduced their drinking behavior and related consequences to a significantly greater extent than controls. Specifically, PNF participants drank 3.4 fewer drinks per week, consumed 0.4 fewer drinks per occasion, binge drank on 1.0 fewer days, and experienced about 1.0 fewer consequences than control participants in the month after the intervention. Intervention effects for drinks per occasion were most pronounced among more problematic drinkers. Changes in perceived norms from baseline to 1-month follow-up mediated intervention efficacy.

CONCLUSION

Though effects were assessed after only 1 month, findings have potential to inform broader, population-level programs designed for young veterans to prevent escalation of drinking and development of long-term alcohol problems. Given the simplicity of the PNF approach and ease of administration, this intervention has the potential for a substantial impact on public health. (PsycINFO Database Record

How does brief motivational intervention change heavy drinking and harm among underage young adult drinkers?

OBJECTIVE

This study tested mediating processes hypothesized to explain the therapeutic benefit of an efficacious motivational interview (MI). The constructs of interest were motivation to change, cognitive dissonance about current drinking, self-efficacy for change, perceived young adult drinking norms, future drinking intentions, and the use of protective behavioral strategies.

METHOD

A randomized controlled trial compared the efficacy of a brief MI to a time- and attention-matched control of meditation and relaxation training for alcohol use. Participants were underage, past-month heavy drinkers recruited from community (i.e., non 4-year college or university) settings (N = 167; ages 17-20; 58% female; 61% White). Statistical analyses assessed mechanisms of MI effects on follow up (6-week, 3-month) percent heavy drinking days (HDD) and alcohol consequences (AC) with a series of temporally lagged mediation models.

RESULTS

MI efficacy for reducing 6-week HDD was mediated by baseline to postsession changes in the following 3 processes: increasing motivation and self-efficacy, and decreasing the amount these young adults intended to drink in the future. For 6-week AC, MI efficacy was mediated through 1 process: decreased perceived drinking norms. At 3-month follow up, increased cognitive dissonance mediated HDD, but not AC. Further, increased use of certain protective behavioral strategies (i.e., avoidance of and seeking alternatives to drinking contexts) from baseline to 6-weeks mediated both 3-month HDD and AC.

CONCLUSIONS

Findings suggest that within-session cognitive changes are key mechanisms of MIs effect on short-term alcohol outcomes among community young adults while protective behaviors may be more operative at subsequent follow up. (PsycINFO Database Record

Mindfulness and Emotion Regulation: Insights from Neurobiological, Psychological, and Clinical Studies

There is increasing interest in the beneficial clinical effects of mindfulness-based interventions (MBIs). Research has demonstrated their efficacy in a wide range of psychological conditions characterized by emotion dysregulation. Neuroimaging studies have evidenced functional and structural changes in a myriad of brain regions mainly involved in attention systems, emotion regulation, and self-referential processing. In this article we review studies on psychological and neurobiological correlates across different empirically derived models of research, including dispositional mindfulness, mindfulness induction, MBIs, and expert meditators in relation to emotion regulation. From the perspective of recent findings in the neuroscience of emotion regulation, we discuss the interplay of top-down and bottom-up emotion regulation mechanisms associated with different mindfulness models. From a phenomenological and cognitive perspective, authors have argued that mindfulness elicits a "mindful emotion regulation" strategy; however, from a clinical perspective, this construct has not been properly differentiated from other strategies and interventions within MBIs. In this context we propose the distinction between top-down and bottom-up mindfulness based emotion regulation strategies. Furthermore, we propose an embodied emotion regulation framework as a multilevel approach for understanding psychobiological changes due to mindfulness meditation regarding its effect on emotion regulation. Finally, based on clinical neuroscientific evidence on mindfulness, we open perspectives and dialogues regarding commonalities and differences between MBIs and other psychotherapeutic strategies for emotion regulation.

Solution Focused Brief Therapy: A Systematic Review and Meta-Summary of Process Research

This article presents a systematic review of the process research on solution-focused brief therapy (SFBT). We searched published and unpublished studies in English across five databases, five major journals, two book chapters, and four websites to locate studies that investigate why and how SFBT works. Thirty-three studies that used various research methods were located and included for further analysis using a meta-summary approach. The findings supported the significance of the co-construction process within SFBT and the effects of specific types of SFBT techniques. The most empirical support was found for the strength-oriented techniques in comparison to the other techniques and for the co-construction of meaning. Current studies require replications with larger samples and experimental designs that study SFBT process in relationship to outcomes.

Transdiagnostic mechanisms of change and cognitive-behavioral treatments for PTSD

This paper reviews the current status of transdiagnostic mechanisms of change targeted in cognitive-behavioral interventions, with a focus on mechanisms that are also relevant to emotional disorders that frequently co-occur with PTSD. First, an overview of the rationale for and key features of identifying mechanisms of change is presented, with a discussion of why it is crucial to examine mechanisms that are relevant across diagnostic boundaries. A review of the current evidence for five promising transdiagnostic mechanisms (hope, neuroticism, emotion regulation, cognitive reappraisal, and anxiety sensitivity) is then provided. Finally, the implications of the increasing evidence of transdiagnostic mechanisms of change are discussed in relation to recently developed transdiagnostic treatment protocols that provide an alternative treatment approach for PTSD.

Semantic Networks, Schema Change, and Reincarceration Outcomes of Therapeutic Community Graduates

BACKGROUND

Therapeutic community (TC) clinical theory assumes that peer interaction forms a framework for social learning that will displace ingrained cognitive schema that underlie substance abuse. There has been no direct test of this hypothesis.

METHODS

We analyzed the content of a large corpus of written affirmations (pushups) and corrections (pull-ups) exchanged between 2342 male TC graduates. We encoded the content of the written communications as semantic networks of words, in which words that appear in the same brief document are connected and are referred to as word combinations. Loss of combinations and gain of combinations each measured an aspect of change in word combination patterns across time. These measures were used in a multivariable Cox model to predict the hazard of reincarceration for residents while controlling for race, age, score on the Level of Service Inventory-Revised and the total number of pushups and pull-ups sent to peers.

RESULTS

Residents' reincarceration risk varied significantly with changes in word combinations used over the course of treatment. The implications of the model were visualized to reveal the complicated nature of the interaction terms included in the model. The visuals suggested that residents who changed their expression patterns the least - lost and gained few word combinations - had the highest reincarceration risk after graduation.

CONCLUSIONS

The results suggest that TC success, in terms of increasing time to reincarceration, depends on how residents change their interaction patterns through the treatment process. Merely interacting with others does not explain success; but whether those interactions change does explain outcomes, which may imply that more fundamental changes are occurring.