A process-based approach to cognitive behavioral therapy: A theory-based case illustration

Mindfulness as a therapeutic option for obsessive-compulsive disorder

INTRODUCTION

Obsessive-compulsive disorder (OCD) is a prevalent mental health issue characterized by intrusive thoughts (obsessions) and repetitive behaviors (compulsions) that can cause significant life impairment. Despite cognitive-behavioral therapy (CBT) being the most effective treatment, some individuals experience insufficient symptom reduction or relapse.

AREAS COVERED

This special report explores the potential of mindfulness-based interventions as complementary treatments for OCD, examining the specific techniques used and their practical application. In the initial section, the authors examine ten randomized control trial studies included in the meta-analysis conducted by Chien et al. (2022), demonstrating the effectiveness of mindfulness interventions. The authors focus on elucidating the specific mindfulness techniques used in these studies. Then, the authors discuss the integration of these mindfulness strategies into CBT, focusing on enhancing emotional regulation, cognitive flexibility, and acceptance of intrusive thoughts.

EXPERT OPINION

While mindful based interventions (MBIs) show promise as adjunctive treatments for OCD, variability in OCD symptoms and treatment responses necessitate individualized therapeutic approaches. Further research is required to refine mindfulness-based techniques and optimize their effectiveness. Incorporating MBIs into standard CBT protocols may improve outcomes for patients with persistent OCD symptoms.

"I feel [so alone] nothing" - emotional vulnerability and detachment as transdiagnostic key characteristics of patients with chronic tinnitus: a schema mode model approach

Background

Gold-standard approaches for chronic tinnitus involve hearing amplification measures and psychological therapy, where applicable. Whilst schema therapy is accumulating evidence as a transdiagnostically useful treatment framework, its applicability for patients with chronic tinnitus has not yet been examined. The present study (a) explores latent dimensions of psychological distress in a sample of chronic tinnitus patients, and (b) examines whether the schema mode model might explain these dimensions - thus constituting a potentially helpful conceptualization and treatment framework.

Methods

N = 696 patients with chronic tinnitus completed the Tinnitus Questionnaire, Tinnitus Handicap Inventory, Hospital Anxiety and Depression Scale, Perceived Stress Questionnaire and ICD-10 Symptom Rating. As criterion, patients further completed the Schema Mode Inventory (SMI-r) - which assesses psychological constructs linked to negative self-beliefs ("parent modes"), primary emotions resulting from unmet psychological needs ("child modes"), and secondary emotional or behavioral attempts to reinstate or maintain psychological equilibrium ("coping modes"). A varimax-rotated principal axis factor analysis grouped the primary item pool. Factor scale scores were then correlated with the SMI-r.

Results

A three-factor solution explained 37.4% of variance and represented 78% of the included items. Following item content examination, the factors represented (1) General emotional distress, (2) Tinnitus-attributed emotional distress, and (3) Socio-audiological impairment. Factors 1|2 correlated highly (r = 0.70), Factors 2|3 moderately (r = 0.62). Linked to the schema mode model, Factor 1 correlated highly with the "vulnerable child" (r = 0.78), and moderately with the "parent", "angry child", and "detached protector" modes (0.53 < r < 0.65). Factor 2 correlated moderately with the "vulnerable child" (r = 0.53). Factor 3 was largely uncorrelated with SMI-r scores - although a low correlation with the "detached protector" warrants further examination.

Conclusion

"General" and "tinnitus-attributed" emotional distress correlate highly - warranting holistic (not symptom-specific) psychological case conceptualization and treatment planning. Viewed from a schema mode perspective, the "vulnerable child" explains substantial variance across both dimensions. Consequently, autobiographically anchored, unmet emotional needs and emotional detachment constitute key treatment targets. Social-audiological impairment should be multimodally conceptualised and treated with hearing aids and psychological support measures, as applicable.

A Review of Transdiagnostic Mechanisms in Cognitive Behavior Therapy

Cognitive behavior therapies (CBTs) are the gold standard treatment for many psychiatric conditions. However, relatively little is known about how CBTs work. By characterizing these mechanisms, researchers can ensure CBTs retain their potency across diagnoses and delivery contexts. We review 3 classes of putative mechanisms: CBT-specific skills (eg, cognitive restructuring, behavioral activation), transtheoretical mechanisms (eg, therapeutic alliance, treatment expectancies, self-efficacy beliefs), and psychopathological mechanisms (aversive reactivity, positive affect, attachment style). We point to future research within each class and emphasize the need for more intensive longitudinal designs to capture how each class of mechanisms interacts with the others to improve outcomes.

Ultra-brief acceptance & commitment therapy for inpatients with psychosis - a single-case experimental design investigating processes of change

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments are not routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient setting. The first aim of the current study was to examine treatment effects of a brief form of Acceptance and Commitment Therapy on outcomes valued by the treatment recipients. The second aim was to explore hypothetical processes of change in relation to outcomes over time. Three people with primary psychosis were treated for two to four sessions. A replicated single-case experimental design with multiple baselines across subjects (Clinical Trials registration number ID NCT04704973) was employed to examine treatment effects. The Personal Questionnaire (PQ) was used as primary outcome, symptom believability and preoccupation as proposed processes of change. Data were analyzed using visual inspection, calculation of Tau-U values, and cross-lagged correlation. All participants improved significantly on PQ and the symptom preoccupation measure. Two improved significantly on the symptom believability measure. Cross-lagged correlation analyses showed no clear mediation. Change in proposed processes of change and primary outcome predominantly happened concomitantly, although patterns of results reflected individual differences.

The Relationship Between Psychological Inflexibility and Well-Being in Adults: A Meta-Analysis of the Acceptance and Action Questionnaire

Psychological inflexibility is defined as the rigid responding to stimuli (e.g., unpleasant thoughts and feelings) that interferes with well-being and valued actions. It is the treatment target in acceptance and commitment therapy (ACT). Despite the centrality of the link between inflexibility and well-being to ACT theory, an empirical review clarifying the nature of this relationship has not been conducted. As such, the current meta-analysis examined the meta-correlation between psychological inflexibility, measured by the Acceptance and Action Questionnaire (AAQ) and its variants, and well-being. A systematic review yielded 151 studies, including 25 versions of the AAQ and 43 well-being measures. Consistent with ACT theory, higher psychological inflexibility was associated with worse well-being (r = -.47, 95% CI[-.49, -.45]). In addition, sample diagnosis, type of AAQ, and type of well-being measure significantly moderated this relationship. Overall, our findings support the hypothesized link between psychological inflexibility and worse well-being. Limitations include reliance on cross-sectional data, precluding causal interpretation.

CBT Meets Process: Assimilative Integration with Reference to Group Psychotherapy

This paper offers a brief overview of the historically predominant form of psychotherapy research both for individual and group psychotherapies, the randomized control trial (RCT), and its surrounding controversies and critiques as the backdrop from which new directions in both clinical theory building and research are being pursued, including efforts at building integrative models of treatment. The paper explores one promising integrative model, namely the incorporation of process and dynamic orientations into the province of group cognitive behavioral therapy (CBT) and identifies challenges in implementing this model.

Do We Need a Novel Framework for Classifying Psychopathology? A Discussion Paper

Introduction

The ICD-11 and DSM-5 are the leading systems for the classification of mental disorders, and their relevance for clinical work and research, as well as their impact for policy making and legal questions, has increased considerably. In recent years, other frameworks have been proposed to supplement or even replace the ICD and the DSM, raising many questions regarding clinical utility, scientific relevance, and, at the core, how best to conceptualize mental disorders.

Method

As examples of the new approaches that have emerged, here we introduce the Hierarchical Taxonomy of Psychopathology (HiTOP), the Research Domain Criteria (RDoC), systems and network approaches, process-based approaches, as well as a new approach to the classification of personality disorders.

Results and Discussion

We highlight main distinctions between these classification frameworks, largely related to different priorities and goals, and discuss areas of overlap and potential compatibility. Synergies among these systems may provide promising new avenues for research and clinical practice.

Using GIMME to model the emotional context of suicidal ideation based on clinical data: From research to clinical practice

Research and clinical experience highlight the variability of suicidal ideation (SI) within and between individuals. Although the idiographic emotional contexts in which SI occurs may offer explanations for its dynamic nature, most statistical methods focus on nomothetic patterns, making it difficult to advance our understanding of SI. Furthermore, the gap between nomothetic methods and a need for idiographic understanding of SI poses challenges to translating empirical knowledge into individualized clinical treatment. Group iterative multiple model estimation (GIMME) is a method that may bridge the idiographic-nomothetic divide by analyzing temporal relationships among a network of variables at both group- and individual-levels. This study explored the feasibility and clinical utility of GIMME applied to examine the relationships between various emotions and SI among individuals with borderline personality disorder who underwent Dialectical Behavior Therapy. We present graphic outputs that emerged throughout treatment and discuss how they could aid clinical assessment and case formulation (ClinicalTrials.gov Identifier: NCT03123198.).

[Chronic tinnitus: An interplay between somatic and psychological factors]

Chronic tinnitus is a common, sometimes highly distressing phenomenon that can be triggered and maintained by an interplay of physical and psychological factors. Partnering with clinical psychology and psychosomatic medicine, modern otolaryngology integrates both medical (e.g., hearing loss) and psychological influences (e.g., interactions between biographical experiences, personality traits, subjective evaluation of intrapsychic and interpersonal stimuli, emotional states, and intrapsychic or interpersonal emotion regulation strategies). Both groups of variables can influence the intensity and course of chronic tinnitus symptomatology both directly and indirectly, whereby the quality and relative degrees of psychological and physical components in a person's self-experience can fluctuate. With this in mind, the present article distinguishes between chronic tinnitus symptomatology with or without hearing loss-and strongly advocates for an integrated understanding of the symptomatology within a holistic psychological frame of reference. After a brief introduction to the principles of psychosomatic medicine and psychotherapy, the article discusses psychological case conceptualization using a vulnerability-stress-coping (VSC) model as an example, outlines clinical aspects and diagnostics of chronic tinnitus symptomatology, and concludes with a conceptualization of chronic tinnitus-related distress as a function of person-centered VSC interactions.

Personalized pain management: Is it time for process-based therapy for particular people with chronic pain?

BACKGROUND AND OBJECTIVE

Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling and distressing pain. At the same time, improvements in the effectiveness of these treatments appear to be at a standstill. This may be due to an inherent lack of generalizability from aggregated group data to the individual, limited utility of our current schemes for categorizing people with pain conditions, faced with their inherent heterogeneity, our relatively coarse categories of treatment types and focus on treatment packages rather than individual methods, and our current failures to find adequate predictors of outcome, or to assign people their best-suited treatment methods, based on group data. In this review, it is argued that the development and examination of truly personalized treatment is a next logical step to create progress and improve the results people achieve.

METHODS

Key research studies pertaining to psychological treatments, treatment outcome, heterogeneity in chronic pain, prediction of treatment outcome, subtyping and treatment tailoring are reviewed.

RESULTS AND CONCLUSION

It is suggested that development of future treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, based on contextually sensitive ongoing assessment. Knowledge and practical solutions needed to make process-based therapy for chronic pain happen are discussed.

SIGNIFICANCE

Psychological approaches to chronic pain have been highly successful in the past but improvement in the effectiveness of these over time is slow to nonexistent. It is argued here that this has happened due to a failure to adequately consider the individual. Future psychological treatments for chronic pain ought to incorporate an idiographic, process-based approach, focused on evidence-based mechanisms of change, individually and dynamically addressed, grounded in ongoing contextually sensitive assessment.