Experimental Manipulations to Test Theory-Driven Mechanisms of Cognitive Behavior Therapy

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

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

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.

Mechanism engagement as a potential evidence-based approach to personalized treatment termination

Objective: This study explores whether early change on a putative mechanism maintaining symptoms can serve as a proximal indicator of response to prompt discontinuation. Method: Patients (N = 70; Mage = 33.74, 67% female, 74% white) with heterogeneous anxiety and depressive disorders completed a sequential multiple assignment randomized trial (SMART). Patients received 6 sessions of skill modules from the Unified Protocol and then underwent a second-stage randomization to either receive the remaining 6 sessions (Full duration) or discontinue treatment (Brief duration). All participants completed weekly self-report measures of anxiety and depressive symptoms and distress aversion for the full 12-week treatment window. We used structural equation modeling to test (1) if distress aversion demonstrated significant variability during the first-stage randomization and (2) if distress aversion during the first-stage randomization predicted second-stage changes in anxiety and depression. Results: Participants demonstrated significant variability in first-stage distress aversion. Latent distress aversion slopes significantly predicted latent second-stage anxiety slopes, whereas latent distress aversion intercepts significantly predicted latent second-stage depression slopes. Conclusions: These results suggest that early mechanism engagement may have potential as a trigger to prompt personalized termination. Shorter courses of care may reduce patient costs and increase the mental health service system's capacity.

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

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

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

Aversive Reactivity: A Transdiagnostic Functional Bridge Between Neuroticism and Avoidant Behavioral Coping

Aversive reactivity to negative affect has been described as a transdiagnostic mechanism that links distal temperamental vulnerabilities to clinically relevant behaviors. However, the abundance of constructs reflecting aversive reactivity has resulted in a proliferation of models that may ultimately be redundant. We performed a circumscribed review of studies measuring associations between six constructs - anxiety sensitivity, experiential avoidance, distress intolerance, intolerance of uncertainty, thought-action fusion, and negative urgency - and ten relevant coping behaviors. Results suggested that most constructs were measured in relation to a limited number of coping behaviors. Additionally, constructs were most often measured in isolation, rather than with similar constructs. Implications and suggestions for future research and treatment are discussed.

Measures of Daily Activities Associated With Mental Health (Things You Do Questionnaire): Development of a Preliminary Psychometric Study and Replication Study

Background

A large body of research has identified modifiable cognitions and behaviors (actions) associated with psychological health. However, little is known regarding the actions that are most strongly associated with psychological health or the frequency with which they should be performed.

Objective

This paper described 2 studies that used survey methodology to create the Things You Do Questionnaire (TYDQ), which aims to identify and rank actions (items) and domains of actions (factors) most strongly associated with psychological health.

Methods

We used digital marketing strategies to recruit Australian adult participants, who were asked to complete 2 web-based surveys comprising versions of the TYDQ; validated measures of depression, anxiety, and satisfaction with life; and demographic questions. In study 1, a total of 3040 participants rated how often they performed each of the 96 items comprising the TYDQ. This design was replicated in study 2, in which a 59-item version of the TYDQ was completed by 3160 participants. In both studies, the factor structure and validity were examined, as were the associations between individual TYDQ items and 3 mental health outcomes: depression, anxiety, and satisfaction with life.

Results

In study 1, factor analyses revealed that a 5-factor model comprising 27 items achieved an optimum balance between brevity and variance and accounted for 38.1%, 31.4%, and 33.2% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively. The factors were interpreted as realistic thinking, meaningful activities, goals and plans, healthy habits, and social connections. These 5 factors were more strongly associated with psychological health than those such as practicing kindness, exercising gratitude, and practicing spirituality. This pattern of results was replicated across gender, age groups, and depression severity. The 5-factor solution found in study 1 was replicated in study 2. Analyses revealed that a 21-item version accounted for 46.8%, 38.2%, and 38.1% of the variance in scores on measures of depression, anxiety, and satisfaction with life, respectively.

Conclusions

These findings indicate that some actions are more strongly associated with psychological health than others and that these activities fall within 5 broad domains, which represent skills often taught in psychological treatments. Subsequent studies are planned to explore the reliability of these items and results in other samples and to examine patterns of change in scores during treatment for anxiety and depression. If replicated, these efforts will assist in the development of new psychological interventions and provide an evidence base for public mental health campaigns designed to promote good mental health and prevent the emergence of common mental disorders.

A Preliminary Evaluation of the Unified Protocol among Trauma-Exposed Adults with and without PTSD

The purpose of this study was to evaluate whether the Unified Protocol (UP)-a mechanistically transdiagnostic psychological treatment-provides benefit to individuals with a range of trauma histories, psychological difficulties, and diagnostic comorbidity. Using data from a sequential multiple-assignment randomized trial (SMART), this exploratory analysis included a sample of 69 community-recruited adults seeking outpatient mental health treatment. We examined reductions in anxiety and depressive symptoms and changes in aversive and avoidant reactions to intense emotions-the UP's putative mechanism-first by comparing individuals with and without trauma histories and then specifically among participants with PTSD. Findings suggest that the UP may lead to similar improvements in clinical diagnostic severity, anxiety, and depression among patients with trauma exposure as those without trauma exposure. Roughly half of participants with PTSD demonstrated reductions in PTSD clinical severity, anxiety, depression, and distress aversion, suggesting the UP may be an efficacious treatment for people with PTSD and comorbid conditions.