The future of psychological treatments: The Marburg Declaration

Although psychological treatments are broadly recognized as evidence-based interventions for various mental disorders, challenges remain. For example, a substantial proportion of patients receiving such treatments do not fully recover, and many obstacles hinder the dissemination, implementation, and training of psychological treatments. These problems require those in our field to rethink some of our basic models of mental disorders and their treatments, and question how research and practice in clinical psychology should progress. To answer these questions, a group of experts of clinical psychology convened at a Think-Tank in Marburg, Germany, in August 2022 to review the evidence and analyze barriers for current and future developments. After this event, an overview of the current state-of-the-art was drafted and suggestions for improvements and specific recommendations for research and practice were integrated. Recommendations arising from our meeting cover further improving psychological interventions through translational approaches, improving clinical research methodology, bridging the gap between more nomothetic (group-oriented) studies and idiographic (person-centered) decisions, using network approaches in addition to selecting single mechanisms to embrace the complexity of clinical reality, making use of scalable digital options for assessments and interventions, improving the training and education of future psychotherapists, and accepting the societal responsibilities that clinical psychology has in improving national and global health care. The objective of the Marburg Declaration is to stimulate a significant change regarding our understanding of mental disorders and their treatments, with the aim to trigger a new era of evidence-based psychological interventions.

Do people know how suicidal they will be? Understanding suicidal prospection

INTRODUCTION

Little research has been done on how people mentally simulate future suicidal thoughts and urges, a process we term suicidal prospection.

METHODS

Participants were 94 adults with recent suicidal thoughts. Participants completed a 42-day real-time monitoring study and then a follow-up survey 28 days later. Each night, participants provided predictions for the severity of their suicidal thoughts the next day and ratings of the severity of suicidal thoughts over the past day. We measured three aspects of suicidal prospection: predicted levels of desire to kill self, urge to kill self, and intent to kill self. We generated prediction errors by subtracting participants' predictions of the severity of their suicidal thoughts from their experienced severity.

RESULTS

Participants tended to overestimate (although the average magnitude was small and the modal error was zero) the severity of their future suicidal thoughts. The best fitting models suggested that participants used both their current suicidal thinking and previous predictions of their suicidal thinking to generate predictions of their future suicidal thinking. Finally, the average severity of predicted future suicidal thoughts predicted the number of days participants thought about suicide during the follow-up period.

CONCLUSIONS

This study highlights prospection as a psychological process to better understand suicidal thoughts and behaviors.

Examining tradeoffs between cognitive effort and relief among adults with self-injurious behavior

BACKGROUND

People engage in nonsuicidal self-injury (NSSI) to reduce negative affect, but it is not clear why they engage in this harmful type of behavior instead of using healthier strategies. The primary goal of this study was to evaluate whether people choose NSSI to reduce negative affect because they perceive it to be less cognitively costly than other available strategies.

METHOD

In experiment one, 43 adults completed a novel, relief-based effort discounting task designed to index preferences about exerting cognitive effort to achieve relief. In experiment two, 149 adults, 52 % with a history of NSSI, completed our effort discounting task.

RESULTS

Our main results suggest that people will accept less relief from an aversive experience if doing so requires expending less effort, i.e. they demonstrate effort discounting in the context of decisions about relief. We also found and that effort discounting is stronger among those with a history of NSSI, but this association became nonsignificant when simultaneously accounting for other conditions associated with aberrant effort tradeoffs.

LIMITATIONS

The use of a control group without NSSI or other potentially harmful relief-seeking behaviors limits our ability to draw specific conclusions about NSSI. The ecological validity of our task was limited by a modestly effective affect manipulation, and because participants made hypothetical choices.

CONCLUSIONS

This study demonstrates that preferences about exerting cognitive effort may be a barrier to using healthier affect regulation strategies. Further, the preference not to exert cognitive effort, though present in NSSI, is likely not unique to NSSI. Instead, effort discounting may be a transdiagnostic mechanism promoting an array of harmful relief-seeking behaviors.

A Cognitive-Behavioral Formulation of Narcissistic Self-Esteem Dysregulation

Narcissistic personality disorder (NPD) is a commonly encountered diagnosis, affecting approximately 1%-6% of the population, with no evidence-based treatments. Recent scholarship has focused on self-esteem dysregulation as a key component of NPD: Excessively high expectations for oneself and how one should be treated leads to brittle self-esteem and maladaptive reactions to self-esteem threats. The current article builds on this formulation, introducing a cognitive-behavioral model of narcissistic self-esteem dysregulation that clinicians can use in providing a relatable model of change for their patients. Specifically, symptoms of NPD can be seen as a set of cognitive and behavioral habits that serve to regulate difficult emotions emerging from maladaptive beliefs and interpretations of self-esteem threats. This perspective renders narcissistic dysregulation amenable to cognitive-behavioral therapy (CBT) in which patients learn skills that help them gain awareness around these habitual reactions, reshape cognitive distortions, and engage in behavioral experiments that serve to transform maladaptive belief systems that consequently free them from symptomatic reactions. Here, we provide a precis of this formulation and examples of how CBT skills can be used to treat narcissistic dysregulation. We also discuss future research that could provide empirical support for the model and test the efficacy of CBT approaches to NPD. Conclusions focus on the notion that narcissistic self-esteem dysregulation likely varies continuously in the population and transdiagnostically across disorders. Greater insight into the cognitive-behavioral mechanisms of self-esteem dysregulation could foster tools for ameliorating distress both in people with NPD and the general populace.

Digital bibliotherapy as a scalable intervention for suicidal thoughts: A randomized controlled trial

OBJECTIVE

Suicide is a major public health concern in the United States, but few effective and scalable interventions exist to help those with suicidal thoughts. We hypothesized that reading first-person narratives about working through suicidal thoughts would reduce the desire to die among adults and that this effect would be mediated by increased perceived shared experience and optimism.

METHOD

Using a randomized waitlist-controlled trial, we tested the effect of digital narrative-based bibliotherapy among 528 adults visiting a social media platform dedicated to providing mental health support. Participants were randomized to either a treatment condition (n = 266), in which they read one suicide narrative per day for 14 days or to a waitlist control condition (n = 262). The primary outcome was a measure of desire to die assessed daily for the 14-day trial period and at 2-week follow-up.

RESULTS

Participants in the treatment condition reported lower desire to die than participants in the control condition during the 14-day trial period (β = -0.26, p = .001) and at 2-week follow-up (t = -2.82, p = .005). Increased perceived shared experience (indirect effect b = -0.55, p < .001) and optimism (indirect effect b = -0.85, p < .001) mediated the effect of treatment on desire to die.

CONCLUSIONS

Digital narrative-based bibliotherapy may be an effective intervention for those at risk for suicide, and may work in part by increasing feelings of perceived shared experience and optimism. Future research is needed to test the generalizability of these results to other platforms, groups, and conditions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Examining implicit positive affect toward suicide among suicidal and nonsuicidal adults and adolescents

OBJECTIVE

The purpose of this study was to examine implicit affect toward suicide (i.e., how good/bad suicide is perceived). Some people might be more likely to think about/choose suicide because they perceive it as a good option (to gain relief) relative to available alternatives.

METHOD

Implicit affect toward suicide among adults (N = 72) and adolescents (N = 174) with and without suicidal thoughts was examined using first-person (FP) perspective suicide pictures in the affect misattribution procedure (AMP).

RESULTS

Suicidal adults' implicit positive affect toward suicide was associated with STB variables, such as explicit valence (r = 0.34) and arousal (r = 0.44) ratings of suicide pictures, and implicit affect differentiated groups above and beyond explicit valence ratings. Contrary to our hypothesis, suicidal participants did not display higher implicit positive affect toward suicide than nonsuicidal participants. However, suicidal participants displayed consistent implicit affect toward different suicide pictures, whereas nonsuicidal participants evaluated some pictures as more pleasant than others (ORs = 1.92-2.27).

CONCLUSIONS

Implicit affect toward suicide may relate to STB, but stimuli characteristics (e.g., color) likely influence the accuracy of assessment with the AMP and should be a focus of future research involving this and other implicit measures.

First-person stimuli: Improving the validity of stimuli in studies of suicide and related behaviors

Researchers are increasingly using objective methods to study constructs related to suicidal thoughts and behavior (STB; e.g., self-identification with suicide), such as via behavioral tasks and brain imaging. Although promising, such approaches often are limited by the use of overly general stimuli (e.g., images, words) to represent constructs under study (e.g., suicide attempt). Overly general stimuli are problematic because they inadequately represent constructs, contributing to measurement error and thereby decreasing the internal and external validity of findings. To address this issue in suicide research specifically, we developed a set of first-person (FP) perspective suicide images depicting suicide attempt, evaluated its psychometric properties in one study, and examined whether people with recent suicidal thoughts rated FP-suicide images differently than people with no history of STB in a second study. Study 1 (N = 221) results suggest FP-suicide images have good construct validity (rs = .66-.87 with other suicide images) and internal consistency (Cronbach αs > .80) across three subjective rating dimensions (i.e., valence, arousal, threat). Study 2 (N = 73) results suggest that people with recent suicidal thoughts display substantially lower aversion toward FP-suicide images (i.e., lower negative valence [d = 1.22, p < .001], lower arousal [d = .61, p < .05] and lower threat ratings [d = 1.27, p < .001]) than people with no STB history. FP-suicide images provide researchers using behavioral tasks/brain imaging paradigms with more self-relevant stimuli that may increase the internal and external validity of findings. First-person stimuli may improve both our understanding and prediction of STB as well as provide novel targets (e.g., lower aversion to suicide) for clinical intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

A brief mobile app reduces nonsuicidal and suicidal self-injury: Evidence from three randomized controlled trials

OBJECTIVE

Self-injurious thoughts and behaviors (SITBs) are a major public health problem that traditional interventions have been unable to address on a large scale. The goal of this series of studies was to take initial steps toward developing an effective SITB treatment that can be easily delivered on a very large scale.

METHOD

We created a brief (1-2 min), game-like app called Therapeutic Evaluative Conditioning (TEC), designed to increase aversion to SITBs and decrease aversion to the self. In 3 separate studies, we recruited participants with recent and severe histories of SITBs from web forums focused on self-injury and psychopathology (Ns = 114, 131, and 163) and randomly assigned them to receive access to the mobile treatment TEC app or a control app for 1 month. We tested the effect of TEC on the frequency of self-cutting, nonsuicidal self-injury more generally, suicide ideation, suicide plans, and suicidal behaviors.

RESULTS

Analyses showed that, compared with the control app, TEC produced moderate reductions for all SITBs except suicide ideation. Across studies, the largest and most consistent reductions were for self-cutting episodes (32%-40%), suicide plans (21%-59%), and suicidal behaviors (33%-77%). Two of the 3 studies showed that TEC impacted its intended treatment targets and that greater change in these targets was associated with greater SITB reductions. TEC effects were not maintained at the 1-month posttreatment follow-up.

CONCLUSIONS

Future versions of brief, mobile interventions like that tested here may have the potential to reduce SITBs and related behaviors on a large scale. (PsycINFO Database Record

Behavioral and electrophysiological correlates of training-induced cognitive control improvements

Cognitive control--the ability to exert control over thoughts, attention and behavior in order to achieve a goal--is essential to adaptive functioning and its disruption characterizes various neuropsychiatric and neurodegenerative disorders. In recent years, increased attention has been devoted to investigating the effects of training on performance and brain function, but little is known about whether cognitive control can be improved through training. To fill this gap, we designed a brief training targeting various components of cognitive control, including conflict monitoring and interference resolution. Twenty participants performed a 3-day training protocol, preceded and followed by identical pre- and post-training sessions, respectively, which included event-related potential (ERP) recordings. To detect transfer effects, the training and pre-/post-training sessions employed different tasks hypothesized to rely on similar interference resolution mechanisms. We hypothesized that training would selectively improve performance for high-interference (i.e., incongruent) trials and be associated with reduced amplitudes in the N2 component, a waveform known to index interference. Trial-to-trial behavioral adjustments were also analyzed to assess potential mechanisms of training-induced improvements. Relative to pre-training, participants showed reduced reaction time (RT) and N2 amplitude for incongruent, but not congruent, trials, suggesting improved interference resolution. Critically, participants showing the greatest reductions in interference effects during the course of the training displayed the largest pre- to post-training reductions in N2 amplitudes in a separate task, highlighting transfer effects. Overall, results suggest that a brief training can improve cognitive control, specifically the ability to inhibit task-irrelevant information.