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  • 1. Andersson, G.
    et al.
    Carlbring, P.
    Holmström, A.
    Sparthan, Elisabeth
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Furmark, Tomas
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Nilsson-Ihrfelt, Elisabeth
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Buhrman, Monica
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Ekselius, Lisa
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience.
    Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial2006In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 74, no 4, p. 677-686Article in journal (Refereed)
    Abstract [en]

    Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen's d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia.

  • 2.
    Andersson, Gerhard
    et al.
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences, Clinical and Social Psychology.
    Carlbring, Per
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences, Clinical and Social Psychology.
    Holmström, Annelie
    Sparthan, Elisabeth
    Furmark, Tomas
    Nilsson-Ihrfelt, Elisabeth
    Buhrman, Monica
    Ekselius, Lisa
    Internet-based self-help with therapist feedback and in vivo group exposure for social phobia: A randomized controlled trial2006In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 74, no 4, p. 677-686Article in journal (Refereed)
    Abstract [en]

    Sixty-four individuals with social phobia (social anxiety disorder) were assigned to a multimodal cognitive-behavioral treatment package or to a waiting list control group. Treatment consisted of a 9-week, Internet-delivered, self-help program that was combined with 2 group exposure sessions in real life and minimal therapist contact via e-mail. Results were analyzed on an intention-to-treat basis, including all randomized participants. From pre- to posttest, treated participants in contrast to controls showed significant improvement on most measured dimensions (social anxiety scales, general anxiety and depression levels, quality of life). The overall within- and between-groups effect sizes were Cohen's d = 0.87 and 0.70, respectively. Treatment gains were maintained at 1-year follow-up. The results from this study support the continued use and development of Internet-distributed, self-help programs for people diagnosed with social phobia. Copyright 2006 by the American Psychological Association.

  • 3. Cochran, Susan D.
    et al.
    Björkenstam, Charlotte
    Stockholm University, Faculty of Social Sciences, Department of Sociology. University of California, Los Angeles, USA.
    Mays, Vickie M.
    Sexual Orientation Differences in Functional Limitations, Disability, and Mental Health Services Use: Results From the 2013-2014 National Health Interview Survey2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 12, p. 1111-1121Article in journal (Refereed)
    Abstract [en]

    Objectives: The authors investigated sexual orientation differences in risk for mental health morbidity, functional limitations/disability, and mental health services use among adults interviewed in the nationally representative 2013-2014 National Health Interview Survey. Method: Respondents were 68,816 adults (67,152 heterosexual and 1,664 lesbian, gay, and bisexual [LGB] individuals), age 18 and older. Fully structured interviews assessed sexual orientation identity, health status, and services use. Using sex-stratified analyses while adjusting for demographic confounding, the authors compared LGB and heterosexual individuals for evidence of mental health-related impairments and use of mental health services. Results: LGB adults, as compared to heterosexual adults, demonstrated higher prevalence of mental health morbidity and functional limitations. However, this varied by gender with LGB women evidencing elevated risk for both mental health and substance abuse (MHSA) and non-MHSA limitations. Among men, sexual orientation differences clustered among MHSA-related limitations. Overall, LGB adults were more likely than heterosexual adults to use services, with the source of functional limitations moderating these effects among men. Conclusion: MHSA-related morbidity is a significant concern among LGB individuals and is associated with higher levels of functional limitations/disability. The findings highlight that LGB persons use MHSA-related treatment at higher rates than heterosexuals do, and, among men, are more likely to do so absent MHSA or non-MHSA-related functional limitations. This presents a unique set of concerns within the integrated care setting, including the need to deliver culturally competent care sensitive to the context of probable sex differences among LGB individuals.

  • 4.
    Cuijpers, Pim
    et al.
    VU University Amsterdam and EMGO Institute.
    van Straten, Annemieke
    VU University Amsterdam and EMGO Institute.
    Andersson, Gerhard
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology.
    van Oppen, Patricia
    VU University Amsterdam and EMGO Institute.
    Psychotherapy for Depression in Adults: A Meta-Analysis of Comparative Outcome Studies2008In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 76, no 6, p. 909-922Article in journal (Refereed)
    Abstract [en]

    Although the subject has been debated and examined for more than 3 decades, it is si ill not clear whether all psychotherapies are equally efficacious. The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment. problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments. Each major type of treatment had been examined in at least 5 randomized comparative trials. There was no indication that I of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective supportive treatment (which was somewhat less efficacious than the other treatments: d = -0.13). The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression.

  • 5.
    Ekeblad, Annika
    et al.
    Linkoping Univ, Dept Behav Res & Learning, S-58183 Linkoping, Sweden.;Sundsvall Hosp, Vasternorrland Cty Council, Psychiat Clin, Sundsvall, Sweden..
    Falkenström, Fredrik
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Psychiatry, University Hospital. Linkoping Univ, Dept Behav Res & Learning, S-58183 Linkoping, Sweden..
    Holmqvist, Rolf
    Linkoping Univ, Dept Behav Res & Learning, S-58183 Linkoping, Sweden..
    Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 1, p. 67-78Article in journal (Refereed)
    Abstract [en]

    Aims: Although considerable attention has been paid to the concept of mentalization in psychotherapy, there is little research on mentalization as predictor of psychotherapy process and outcome. Using data from a randomized controlled trial of cognitive-behavioral therapy and interpersonal psychotherapy for depression, we studied mentalization in 85 outpatients with major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders. It was hypothesized that patients showing lower capacity for mentalization would experience poorer quality of alliance and worse outcome. Method: Depressive symptoms were measured each session using the Beck Depression Inventory-II. Mentalization was measured as reflective functioning (RF) on a slightly shortened version of the Adult Attachment Interview. A measure of depression-specific reflective functioning (DSRF), measuring mentalization about depressive symptoms, was also used. The Working Alliance Inventory-Short Form Revised was completed after each session by both therapist and patient. Longitudinal multilevel modeling was used to analyze data. Results: The patients had on average very low RF (M = 2.62, SD = 1.22). Lower pretreatment RF/DSRF predicted significantly lower therapist-rated working alliance during treatment. RF did not affect patient-rated alliance, but lower DSRF predicted lower patient-rated alliance across treatment. Patients with higher RF/DSRF had better outcomes on self-rated depression. Conclusions: The findings showed lower than normal capacity for mentalization in patients with MDD. Lower RF/DSRF predicted worse treatment outcome. More research is needed to understand how RF affects psychotherapy response and how RF is affected after recovery from depression.

  • 6.
    Ekeblad, Annika
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Sundsvall Hospital, Sweden.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Reflective Functioning as Predictor of Working Alliance and Outcome in the Treatment of Depression2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 1, p. 67-78Article in journal (Refereed)
    Abstract [en]

    Aims: Although considerable attention has been paid to the concept of mentalization in psychotherapy, there is little research on mentalization as predictor of psychotherapy process and outcome. Using data from a randomized controlled trial of cognitive-behavioral therapy and interpersonal psychotherapy for depression, we studied mentalization in 85 outpatients with major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders. It was hypothesized that patients showing lower capacity for mentalization would experience poorer quality of alliance and worse outcome. Method: Depressive symptoms were measured each session using the Beck Depression Inventory-II. Mentalization was measured as reflective functioning (RF) on a slightly shortened version of the Adult Attachment Interview. A measure of depression-specific reflective functioning (DSRF), measuring mentalization about depressive symptoms, was also used. The Working Alliance Inventory-Short Form Revised was completed after each session by both therapist and patient. Longitudinal multilevel modeling was used to analyze data. Results: The patients had on average very low RF (M = 2.62, SD = 1.22). Lower pretreatment RF/DSRF predicted significantly lower therapist-rated working alliance during treatment. RF did not affect patient-rated alliance, but lower DSRF predicted lower patient-rated alliance across treatment. Patients with higher RF/DSRF had better outcomes on self-rated depression. Conclusions: The findings showed lower than normal capacity for mentalization in patients with MDD. Lower RF/DSRF predicted worse treatment outcome. More research is needed to understand how RF affects psychotherapy response and how RF is affected after recovery from depression.

  • 7.
    El Alaoui, S.
    et al.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Hedman, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Osher Center for Integrative Medicine, Karolinska Institutet, Stockholm, Sweden.
    Kaldo, V.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden.
    Kraepelien, M.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Rück, C.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Andersson, G.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Ljótsson, B.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Lindefors, N.
    Department of Clinical Neuroscience, Division of Psychiatry, Karolinska University Hospital, Stockholm, Sweden.
    Effectiveness of Internet-based cognitive-behavior therapy for social anxiety disorder in clinical psychiatry2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 5, p. 902-914Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinic's years of experience in delivering ICBT.

    Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated.

    Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinic's years of experience with ICBT and treatment outcome was also observed.

    Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.

  • 8.
    El Alaoui, Samir
    et al.
    Karolinska Institutet.
    Hedman, Erik
    Karolinska Institutet.
    Kaldo, Viktor
    Karolinska Institutet.
    Hesser, Hugo
    Linköping University.
    Kraepelien, Martin
    Karolinska Institutet.
    Andersson, Evelyn
    Karolinska Institutet.
    Ruck, Christian
    Karolinska Institutet.
    Andersson, Gerhard
    Karolinska Institutet;Linköping University.
    Ljotsson, Brjann
    Karolinska Institutet.
    Lindefors, Nils
    Karolinska Institutet.
    Effectiveness of Internet-Based Cognitive-Behavior Therapy for Social Anxiety Disorder in Clinical Psychiatry2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 5, p. 902-914Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinic's years of experience in delivering ICBT. Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated. Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinic's years of experience with ICBT and treatment outcome was also observed. Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.

  • 9.
    El Alaoui, Samir
    et al.
    Karolinska Institute, Sweden.
    Hedman, Erik
    Karolinska Institute, Sweden; Karolinska Institute, Sweden.
    Kaldo, Viktor
    Karolinska Institute, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kraepelien, Martin
    Karolinska Institute, Sweden.
    Andersson, Evelyn
    Karolinska Institute, Sweden.
    Ruck, Christian
    Karolinska Institute, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Ljotsson, Brjann
    Karolinska Institute, Sweden.
    Lindefors, Nils
    Karolinska Institute, Sweden.
    Effectiveness of Internet-Based Cognitive-Behavior Therapy for Social Anxiety Disorder in Clinical Psychiatry2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 5, p. 902-914Article in journal (Refereed)
    Abstract [en]

    Objective: Internet-based cognitive-behavioral therapy (ICBT) has received increased attention as an innovative approach to improve access to evidence-based psychological treatments. Although the efficacy of ICBT for social anxiety disorder has been established in several studies, there is limited knowledge of its effectiveness and application in clinical psychiatric care. The purpose of this study was to evaluate the effectiveness of ICBT in the treatment of social anxiety disorder and to determine the significance of patient adherence and the clinics years of experience in delivering ICBT. Method: A longitudinal cohort study was conducted using latent growth curve modeling of patients (N = 654) treated with ICBT at an outpatient psychiatric clinic between 2009 and 2013. The primary outcome measure was the Liebowitz Social Anxiety Scale-Self-Rated. Results: Significant reductions in symptoms of social anxiety were observed after treatment (effect size d = 0.86, 99% CI [0.74, 0.98]). Improvements were sustained at 6-month follow-up (d = 1.15, 99% CI [0.99, 1.32]). Patient adherence had a positive effect on the rate of improvement. A positive association between the clinics years of experience with ICBT and treatment outcome was also observed. Conclusions: This study suggests that ICBT for social anxiety disorder is effective when delivered within the context of a unit specialized in Internet-based psychiatric care and may be considered as a treatment alternative for implementation within the mental health care system.

  • 10.
    Erbes, C. R.
    et al.
    Minneapolis VA Healthcare System, Minneapolis MN, United States; Center for Chronic Disease Outcomes Research, Minneapolis MN, United States; Department of Psychiatry, University of Minnesota, United States.
    Kramer, Mark
    Department of Psychiatry, University of Minnesota, United States.
    Arbisi, P. A.
    Minneapolis VA Healthcare System, Minneapolis MN, United States; Department of Psychiatry, University of Minnesota, United States.
    DeGarmo, D
    Department of Educational Methodology, Policy, and Leadership, University of Oregon, United States.
    Polusny, M. A.
    Minneapolis VA Healthcare System, Minneapolis MN, United States; Center for Chronic Disease Outcomes Research, Minneapolis MN, United States; Department of Psychiatry, University of Minnesota, United States.
    Characterizing spouse/partner depression and alcohol problems over the course of military deployment2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 4, p. 297-308Article in journal (Refereed)
    Abstract [en]

    Objective: Spouse/partners of military personnel demonstrate elevated levels of distress during military deployments, yet there is insufficient information about courses of adjustment over time. The current study identified trajectories of depression and alcohol use problems and predictors of those trajectories across the deployment cycle.

    Method: National Guard soldiers (N = 1973) and spouses/intimate partners (N = 1020) completed assessments of risk/protective factors and baseline measures of mental health functioning 2 to 5 months prior to soldiers' 1-year deployments (Time 1) to Kuwait/Iraq in support of Operation New Dawn or Afghanistan in support of Operation Enduring Freedom. Partners' mental health was reassessed at 4 months (Time 2) and 8 months (Time 3) after soldiers deployed, and both spouses/partners and soldiers were reassessed 2-3 months postdeployment (Time 4).

    Results: Latent class growth modeling of partner depression symptoms over time revealed 4 groups: Resilience (79.9%), Deployment Distress (8.9%), Anticipatory Distress (8.4%), and Post-Deployment Distress (2.7%). Three alcohol misuse trajectories were identified: Resilience (91.3%), Deployment Onset (5.4%), and Deployment Desistance (3.3%). Predeployment predictors of partners' depression symptom trajectories varied by group and included soldier reports of stressors and social support and partner levels of neuroticism, introversion, disconstraint, and reported stressors. Predeployment predictors of alcohol misuse trajectories varied by group, and included soldier levels of alcohol misuse as well as partner neuroticism, disconstraint, and family readiness.

    Conclusions: Delineating and predicting trajectories of partner adjustment can allow for better targeted interventions toward those most at risk for heightened distress or alcohol problems over the deployment cycle.

  • 11.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Uppsala University, Sweden.
    Ekeblad, Annika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences. Vasternorrland County Council, Sweden.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 8, p. 738-751Article in journal (Refereed)
    Abstract [en]

    Objective: Developments in working alliance theory posit that the therapists attention to fluctuations in the alliance throughout treatment is crucial. Accordingly, researchers have begun studying the alliance as a time-varying mechanism of change rather than as a static moderator. However, most studies to date suffer from bias owing to the nonindependence of error term and predictors (endogeneity). Method: Patients with major depressive disorder (N = 84) from a randomized trial comparing cognitive-behavioral therapy with interpersonal psychotherapy filled out the Beck Depression Inventory-II before each session. After each session, patients and therapists filled out the Working Alliance Inventory short forms. Data were analyzed using the generalized method of moments for dynamic panel data, a method commonly applied in econometrics to eliminate endogeneity bias. Results: Improvement of the alliance predicted significant reduction of depressive symptoms by the next session (patient rating: b = -4.35, SE = 1.96, p = .026, 95% confidence interval [CI] [-8.19, -0.51]; therapist rating: b = -4.92, SE = 1.84, p = .008, 95% CI [-8.53, -1.31]). In addition, there was a significant delayed effect on the session after the next (patient rating: b = -3.25, SE = 1.20, p = .007, 95% CI [-5.61, -0.89]; therapist rating: b = -5.44, SE = 1.92, p = .005, 95% CI [-9.20, -1.68]). Conclusion: If the quality of patient-therapist alliance is improved in a given treatment session, depressive symptoms will likely decrease by the next session. The most important limitation of this study is its relatively small sample size.

  • 12.
    Falkenström, Fredrik
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience. Linkoping Univ, Dept Behav Sci & Learning, Lustigkullevagen 17, S-58183 Linkoping, Sweden..
    Ekeblad, Annika
    Linkoping Univ, Dept Behav Sci & Learning, Lustigkullevagen 17, S-58183 Linkoping, Sweden.;Vasternorrland Cty Council, Psychiat Clin, Harnosand, Vasternorrland, Sweden..
    Holmqvist, Rolf
    Linkoping Univ, Dept Behav Sci & Learning, Lustigkullevagen 17, S-58183 Linkoping, Sweden..
    Improvement of the Working Alliance in One Treatment Session Predicts Improvement of Depressive Symptoms by the Next Session2016In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 84, no 8, p. 738-751Article in journal (Refereed)
    Abstract [en]

    Objective: Developments in working alliance theory posit that the therapist's attention to fluctuations in the alliance throughout treatment is crucial. Accordingly, researchers have begun studying the alliance as a time-varying mechanism of change rather than as a static moderator. However, most studies to date suffer from bias owing to the nonindependence of error term and predictors (endogeneity). Method: Patients with major depressive disorder (N = 84) from a randomized trial comparing cognitive-behavioral therapy with interpersonal psychotherapy filled out the Beck Depression Inventory-II before each session. After each session, patients and therapists filled out the Working Alliance Inventory short forms. Data were analyzed using the generalized method of moments for dynamic panel data, a method commonly applied in econometrics to eliminate endogeneity bias. Results: Improvement of the alliance predicted significant reduction of depressive symptoms by the next session (patient rating: b = -4.35, SE = 1.96, p = .026, 95% confidence interval [CI] [-8.19, -0.51]; therapist rating: b = -4.92, SE = 1.84, p = .008, 95% CI [-8.53, -1.31]). In addition, there was a significant delayed effect on the session after the next (patient rating: b = -3.25, SE = 1.20, p = .007, 95% CI [-5.61, -0.89]; therapist rating: b = -5.44, SE = 1.92, p = .005, 95% CI [-9.20, -1.68]). Conclusion: If the quality of patient-therapist alliance is improved in a given treatment session, depressive symptoms will likely decrease by the next session. The most important limitation of this study is its relatively small sample size.

  • 13.
    Falkenström, Fredrik
    et al.
    Karolinska Institute, Sweden; Stockholm County Council, Sweden.
    Finkel, Steven
    University of Pittsburgh, PA 15260 USA.
    Sandell, Rolf
    Lund University, Sweden.
    Rubel, Julian A.
    University of Trier, Germany.
    Holmqvist, Rolf
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Dynamic Models of Individual Change in Psychotherapy Process Research2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 6, p. 537-549Article in journal (Refereed)
    Abstract [en]

    Objective: There is a need for rigorous methods to study the mechanisms that lead to individual-level change (i.e., process-outcome research). We argue that panel data (i.e., longitudinal study of a number of individuals) methods have 3 major advantages for psychotherapy researchers: (1) enabling microanalytic study of psychotherapeutic processes in a clinically intuitive way, (2) modeling lagged associations over time to ensure direction of causality, and (3) isolating within-patient changes over time from between-patient differences, thereby protecting against confounding influences because of the effects of unobserved stable attributes of individuals. However, dynamic panel data methods present a complex set of analytical challenges. We focus on 2 particular issues: (1) how long-term trajectories in the variables of interest over the study period should be handled, and (2) how the use of a lagged dependent variable as a predictor in regression-based dynamic panel models induces endogeneity (i.e., violation of independence between predictor and model error term) that must be taken into account in order to appropriately isolate within-and between-person effects. Method: An example from a study of working alliance in psychotherapy in primary care in Sweden is used to illustrate some of these analytic decisions and their impact on parameter estimates. Results: Estimates were strongly influenced by the way linear trajectories were handled; that is, whether variables were "detrended" or not. Conclusions: The issue of when detrending should be done is discussed, and recommendations for research are provided. What is the public health significance of this article? This article provides recommendations on how to study psychotherapy processes using dynamic panel data models to strengthen causal inferences. Accurate estimates of what drives individual development in psychotherapy are needed to generate recommendations on what therapists should focus on in therapy. Using the alliance-outcome association as an example, we show that estimated effect sizes may vary greatly depending on which modeling approach is used, with the decision on whether to remove time-trends from the outcome variable making the largest difference.

  • 14.
    Falkenström, Fredrik
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Kuria, Mary
    Univ Nairobi, Kenya.
    Othieno, Caleb
    Univ Nairobi, Kenya.
    Kumar, Manasi
    Univ Nairobi, Kenya.
    Working Alliance Predicts Symptomatic Improvement in Public Hospital-Delivered Psychotherapy in Nairobi, Kenya2019In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 87, no 1, p. 46-55Article in journal (Refereed)
    Abstract [en]

    Objective: Although patient-therapist collaboration (working alliance) has been studied extensively in Europe and America, it is unknown to what extent the importance of working alliance for psychotherapy outcome generalizes to lower-and middle-income countries. Additionally, there is a need for more studies on the alliance using methods that are robust to confounders of its effect on outcome. Method: In this study, 345 outpatients seeking care at the 2 public psychiatric hospitals in Nairobi, Kenya, filled out the Session Alliance Inventory (SAI) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) during each session. The effect of alliance on next-session psychological distress was modeled using the random intercept cross-lagged panel model, which estimates a cross-lagged panel model on within- and between-subjects disaggregated data. Results: Changes in the working alliance from session to session significantly predicted change in psychological distress by the next session, with an increase of 1 point of the SAI in a given session resulting in a decrease of 1.27 points on the CORE-OM by the next session (SE = 60, 95% confidence interval [-2.44, -.10]). This finding represents a medium-sized standardized regression coefficient of between.16 and.21. Results were generally robust to sensitivity tests for stationarity, missing data assumptions, and measurement error. Conclusion: Results affirm cross-cultural stability of the session-by-session reciprocal effects model of alliance and psychological distress-symptoms as seen in a Kenyan psychiatric outpatient sample, using the latest developments in cross-lagged panel modeling. A limitation of the study is its naturalistic design and lack of control over several variables.

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  • 15.
    Fitzpatrick, Olivia M.
    et al.
    Ohio State Univ, OH 43210 USA; Harvard Univ, MA 02138 USA.
    Whelen, Megan L.
    Ohio State Univ, OH 43210 USA.
    Falkenström, Fredrik
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Strunk, Daniel R.
    Ohio State Univ, OH 43210 USA.
    Who Benefits the Most From Cognitive Change in Cognitive Therapy of Depression? A Study of Interpersonal Factors2020In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, no 2, p. 128-136Article in journal (Refereed)
    Abstract [en]

    Objective: Research suggests that decreases in negative cognitions coincide with symptom improvements over the course of cognitive therapy (CT) of depression, but the role cognitive change (CC) plays in reducing symptoms remains controversial. Method: A total of 126 adults (mean age = 31.7, SD = 13.35; 60% female; 83% Caucasian) participated in CT for depression. Patients completed the Beck Depression Inventory-II and the Immediate Cognitive Change Scale at each session. At intake evaluation, maladaptive personality traits (Personality Inventory for DSM-5, Brief Form) and interpersonal problems (Inventory of Interpersonal Problems, Short Version) were assessed via self-report, and social skills were assessed through patients evaluation of their performance following a series of behavioral role-plays (standardized interaction task). To rule out between-patient differences as potential confounds, our model disaggregated within- and between-patient components of CC and depression scores. Results: Within-patient CC significantly predicted within-patient change in depressive symptoms. This relation was moderated by patients evaluations of their social skills and patients level of interpersonal problems, with CC predicting symptoms more robustly for patients with fewer perceived social skills and for those with greater interpersonal problems. Maladaptive personality traits did not emerge as a moderator. Additional analyses showed the relation of CC and symptom change was particularly strong among those with social anxiety disorder and among those observers rated as having lower social skills. Conclusions: CC in CT sessions appears to foster subsequent depressive symptom reduction, especially among patients with lower levels of self-evaluated social skills and greater interpersonal problems.

  • 16.
    Forsell, Erik
    et al.
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Isacsson, Nils
    Institutet, Sweden;Stockholm County Council, Sweden.
    Blom, Kerstin
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Jernelov, Susanna
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Ben Abdesslem, Fehmi
    RISE, Sweden.
    Lindefors, Nils
    Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Boman, Magnus
    KTH Royal instute of technology, Sweden.
    Kaldo, Viktor
    Linnaeus University, Faculty of Health and Life Sciences, Department of Psychology. Karolinska Institutet, Sweden;Stockholm County Council, Sweden.
    Predicting Treatment Failure in Regular Care Internet-Delivered Cognitive Behavior Therapy for Depression and Anxiety Using Only Weekly Symptom Measures2020In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, no 4, p. 311-321Article in journal (Refereed)
    Abstract [en]

    Objective: Therapist guided Internet-Delivered Cognitive Behavior Therapy (ICBT) is effective, but as in traditional CBT, not all patients improve, and clinicians generally fail to identify them early enough. We predict treatment failure in 12-week regular care ICBT for Depression, Panic disorder and Social anxiety disorder, using only patients' weekly symptom ratings to identify when the accuracy of predictions exceed 2 benchmarks: (a) chance, and (b) empirically derived clinician preferences for actionable predictions. Method: Screening, pretreatment and weekly symptom ratings from 4310 regular care ICBT-patients from the Internet Psychiatry Clinic in Stockholm, Sweden was analyzed in a series of regression models each adding 1 more week of data. Final score was predicted in a holdout test sample, which was then categorized into Success or Failure (failure defined as the absence of both remitter and responder status). Classification analyses with Balanced Accuracy and 95% Confidence intervals was then compared to predefined benchmarks. Results: Benchmark 1 (better than chance) was reached 1 week into all treatments. Social anxiety disorder reached Benchmark 2 (>65%) at week 5, whereas Depression and Panic Disorder reached it at week 6. Conclusions: For depression, social anxiety and panic disorder, prediction with only patient-rated symptom scores can detect treatment failure 6 weeks into ICBT, with enough accuracy for a clinician to take action. Early identification of failing treatment attempts may be a viable way to increase the overall success rate of existing psychological treatments by providing extra clinical resources to at-risk patients, within a so-called Adaptive Treatment Strategy.

  • 17.
    Forsell, Erik
    et al.
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden..
    Isacsson, Nils
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden..
    Blom, Kerstin
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden..
    Jernelov, Susanna
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden..
    Ben Abdesslem, Fehmi
    RISE Res Inst Sweden, Stockholm, Sweden..
    Lindefors, Nils
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden..
    Boman, Magnus
    KTH, School of Electrical Engineering and Computer Science (EECS), Computer Science, Software and Computer systems, SCS.
    Kaldo, Viktor
    Karolinska Inst, Ctr Psychiat Res, Dept Clin Neurosci, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Stockholm Hlth Care Serv, Internetpsykiatrienheten M58, S-14120 Stockholm, Sweden.;Linnaeus Univ, Dept Psychol, Fac Hlth & Life Sci, Vaxjo, Sweden..
    Predicting Treatment Failure in Regular Care Internet-Delivered Cognitive Behavior Therapy for Depression and Anxiety Using Only Weekly Symptom Measures2020In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, no 4, p. 311-321Article in journal (Refereed)
    Abstract [en]

    Objective: Therapist guided Internet-Delivered Cognitive Behavior Therapy (ICBT) is effective, but as in traditional CBT, not all patients improve, and clinicians generally fail to identify them early enough. We predict treatment failure in 12-week regular care ICBT for Depression, Panic disorder and Social anxiety disorder, using only patients' weekly symptom ratings to identify when the accuracy of predictions exceed 2 benchmarks: (a) chance, and (b) empirically derived clinician preferences for actionable predictions. Method: Screening, pretreatment and weekly symptom ratings from 4310 regular care ICBT-patients from the Internet Psychiatry Clinic in Stockholm, Sweden was analyzed in a series of regression models each adding 1 more week of data. Final score was predicted in a holdout test sample, which was then categorized into Success or Failure (failure defined as the absence of both remitter and responder status). Classification analyses with Balanced Accuracy and 95% Confidence intervals was then compared to predefined benchmarks. Results: Benchmark 1 (better than chance) was reached 1 week into all treatments. Social anxiety disorder reached Benchmark 2 (>65%) at week 5, whereas Depression and Panic Disorder reached it at week 6. Conclusions: For depression, social anxiety and panic disorder, prediction with only patient-rated symptom scores can detect treatment failure 6 weeks into ICBT, with enough accuracy for a clinician to take action. Early identification of failing treatment attempts may be a viable way to increase the overall success rate of existing psychological treatments by providing extra clinical resources to at-risk patients, within a so-called Adaptive Treatment Strategy.

  • 18.
    Forsell, Erik
    et al.
    Karolinska Institute, Sweden.
    Isacsson, Nils
    Karolinska Institute, Sweden.
    Blom, Kerstin
    Karolinska Institute, Sweden.
    Jernelöv, Susanna
    Karolinska Institute, Sweden.
    Ben Abdesslem, Fehmi
    RISE - Research Institutes of Sweden (2017-2019), ICT, SICS.
    Lindefors, Nils
    Karolinska Institute, Sweden.
    Boman, Magnus
    KTH Royal Institute of Technology, Sweden.
    Kaldo, Viktor
    Karolinska Institute, Sweden.
    Predicting treatment failure in regular care Internet-Delivered Cognitive Behavior Therapy for depression and anxiety using only weekly symptom measures.2019In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Therapist guided Internet-Delivered Cognitive Behavior Therapy (ICBT) is effective, but as in traditional CBT, not all patients improve, and clinicians generally fail to identify them early enough. We predict treatment failure in 12-week regular care ICBT for Depression, Panic disorder and Social anxiety disorder, using only patients' weekly symptom ratings to identify when the accuracy of predictions exceed 2 benchmarks: (a) chance, and (b) empirically derived clinician preferences for actionable predictions.

    METHOD: Screening, pretreatment and weekly symptom ratings from 4310 regular care ICBT-patients from the Internet Psychiatry Clinic in Stockholm, Sweden was analyzed in a series of regression models each adding 1 more week of data. Final score was predicted in a holdout test sample, which was then categorized into Success or Failure (failure defined as the absence of both remitter and responder status). Classification analyses with Balanced Accuracy and 95% Confidence intervals was then compared to predefined benchmarks.

    RESULTS: Benchmark 1 (better than chance) was reached 1 week into all treatments. Social anxiety disorder reached Benchmark 2 (> 65%) at week 5, whereas Depression and Panic Disorder reached it at week 6.

    CONCLUSIONS: For depression, social anxiety and panic disorder, prediction with only patient-rated symptom scores can detect treatment failure 6 weeks into ICBT, with enough accuracy for a clinician to take action. Early identification of failing treatment attempts may be a viable way to increase the overall success rate of existing psychological treatments by providing extra clinical resources to at-risk patients, within a so-called Adaptive Treatment Strategy. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

  • 19.
    Guy, L. S.
    et al.
    Department of Psychology, Simon Fraser University, Canada; Department of Psychology, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6, Canada .
    Anthony, C.
    Department of Psychology, Sam Houston State University, United States.
    Edens, J. F.
    Department of Psychology, Southern Methodist University, United States.
    Douglas, K. S.
    Mid Sweden University, Faculty of Human Sciences, Department of Health Sciences. Department of Psychology, Simon Fraser University, Canada; Department of Applied Criminology.
    Does psychopathy predict institutional misconduct among adults?: A meta-analytic investigation2005In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 73, no 6, p. 1056-1064Article in journal (Refereed)
    Abstract [en]

    Narrative reviews have raised several questions regarding the predictive validity of the Hare Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 2003) and related scales in institutional settings. In this meta-analysis, the authors coded 273 effect sizes to investigate the association between the Hare scales and a hierarchy of increasingly specific forms of institutional misconduct. Effect sizes for Total, Factor 1, and Factor 2 scores were quite heterogeneous overall and weakest for physically violent misconduct (r w = .17, .14, and .15, respectively). Moderator analyses suggested that physical violence effect sizes were smaller in U.S. prison samples (r w = .11) than in non-U.S. prison samples (r w = .23). Findings are discussed in terms of the utility of the Hare measures for decision-making in institutional and other contexts.

  • 20.
    Hesser, Hugo
    et al.
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Tore
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Lundén, Charlotte
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Henrikson, Oskar
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Fattahi, Kidjan
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Johnsson, Erik
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Westin Zetterqvist, Vendela
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Educational Sciences.
    Carlbring, Per
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Mäki-Torkko, Elina
    Linköping University, Department of Clinical and Experimental Medicine, Technical Audiology. Linköping University, Faculty of Health Sciences.
    Kaldo, Viktor
    Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Gerhard
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus2012In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, p. 649-661Article in journal (Refereed)
    Abstract [en]

    Objective: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format. Method: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up. Results: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16). Conclusions: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

  • 21.
    Hesser, Hugo
    et al.
    Linköping University.
    Gustafsson, Tore
    Linköping Uiversity.
    Lundén, Charlotte
    Linköping University.
    Henrikson, Oskar
    Linköping University.
    Fattahi, Kidjan
    Linköping University.
    Johnsson, Erik
    Linköping University.
    Zetterqvist Westin, Vendela
    Linköping University.
    Carlbring, Per
    Umeå University, Faculty of Social Sciences, Department of Psychology.
    Mäki-Torkko, Elina
    Linköping University.
    Kaldo, Viktor
    Karolinska Institutet, Stockholm.
    Andersson, Gerhard
    Linköping University and Karolinska Institutet.
    A Randomized Controlled Trial of Internet-Delivered Cognitive Behavior Therapy and Acceptance and Commitment Therapy in the Treatment of Tinnitus2012In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, p. 649-661Article in journal (Refereed)
    Abstract [en]

    Objective:

    Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format.

    Method:

    Ninety-nine participants (mean age 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n 32), ACT (n 35), or a control condition (monitored Internet discussion forum; n 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up.

    Results:

    Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [17.03, 2.94], d 0.70, and 95% CI [16.29, 2.53], d 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [44.65, 20.45], d 1.34), with no significant difference between treatments (95% CI [14.87, 11.21], d 0.16).

    Conclusions:

    Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

  • 22.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Gustafsson, Tore
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Lundén, Charlotte
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Henrikson, Oskar
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Fattahi, Kidjan
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Johnsson, Erik
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Zetterqvist Westin, Vendela
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden.
    Carlbring, Per
    Department of Psychology, Umeå University, Umeå, Sweden.
    Mäki-Torkko, Elina
    Örebro University, School of Medical Sciences. Department of Clinical and Experimental Medicine, Division of Technical Audiology, Linköping University, Linköping, Sweden; Department of ENT-Head Neck Surgery UHL, County Council of Östergötland, Linköping, Sweden.
    Kaldo, Viktor
    Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Gerhard
    Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Psychiatric Section, Karolinska Institutet, Stockholm, Sweden.
    A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus2012In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 80, no 4, p. 649-661Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Our aim in this randomized controlled trial was to investigate the effects on global tinnitus severity of 2 Internet-delivered psychological treatments, acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT), in guided self-help format.

    METHOD: Ninety-nine participants (mean age = 48.5 years; 43% female) who were significantly distressed by tinnitus were recruited from the community. Participants were randomly assigned to CBT (n = 32), ACT (n = 35), or a control condition (monitored Internet discussion forum; n = 32), and they were assessed with standardized self-report measures (Tinnitus Handicap Inventory; Hospital Anxiety and Depression Scale; Quality of Life Inventory; Perceived Stress Scale; Tinnitus Acceptance Questionnaire) at pre-, posttreatment (8 weeks), and 1-year follow-up.

    RESULTS: Mixed-effects linear regression analysis of all randomized participants showed significant effects on the primary outcome (Tinnitus Handicap Inventory) for CBT and for ACT compared with control at posttreatment (95% CI [-17.03, -2.94], d = 0.70, and 95% CI [-16.29, -2.53], d = 0.68, respectively). Within-group effects were substantial from pretreatment through 1-year-follow-up for both treatments (95% CI [-44.65, -20.45], d = 1.34), with no significant difference between treatments (95% CI [-14.87, 11.21], d = 0.16).

    CONCLUSIONS: Acceptance-based procedures may be a viable alternative to traditional CBT techniques in the management of tinnitus. The Internet can improve access to psychological interventions for tinnitus.

  • 23.
    Hesser, Hugo
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hedman-Lagerlöf, Erik
    Karolinska Inst, Sweden.
    Andersson, Erik
    Karolinska Inst, Sweden.
    Lindfors, Perjohan
    Karolinska Inst, Sweden; Univ Gothenburg, Sweden.
    Ljotsson, Brjann
    Karolinska Inst, Sweden.
    How Does Exposure Therapy Work? A Comparison Between Generic and Gastrointestinal Anxiety-Specific Mediators in a Dismantling Study of Exposure Therapy for Irritable Bowel Syndrome2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 3, p. 254-267Article in journal (Refereed)
    Abstract [en]

    Objective: Systematic exposure is potentially an effective treatment procedure for treating irritable bowel syndrome (IBS), but little is known about the processes by which it achieves its effect on outcome. The aim of this study was to identify mediators in a previously published randomized dismantling trial in which participants with IBS were randomized to Internet-delivered cognitive-behavioral treatment (ICBT) that incorporated systematic exposure or to the same treatment protocol without exposure (ICBT-WE). Method: Weekly measurements of gastrointestinal anxiety-specific process variables (behavioral avoidance, gastrointestinal-specific anxiety) based on the gastrointestinal symptom-specific anxiety model, generic process variables (self-efficacy and mindful nonreactivity), and treatment outcome (IBS symptoms) were obtained from 309 participants with IBS. Growth models and cross-lagged panel models, estimated within structural equation modeling, were employed to evaluate mediators of outcome. Results: Parallel process growth modeling showed that behavioral avoidance, gastrointestinal-specific anxiety, self-efficacy mediated the incremental effect of ICBT compared to ICBT-WE. The mediated effect of avoidance was stronger for individuals scoring high on the avoidance variable at 1st measurement point. Cross-lagged regression analyses with random effects revealed that behavioral avoidance and gastrointestinal-specific anxiety had a stronger effect on subsequent symptom change rather than vice versa, whereas mindful nonreactivity and self-efficacy displayed the opposite pattern. Conclusions: The evidence collectively provided support for the hypothesis that exposure for IBS achieves its positive results by virtue of changing gastrointestinal anxiety-specific processes rather than generic processes. IBS-specific behavioral avoidance emerged as the most clear-cut mediator of the specific effect of exposure on outcome.

  • 24.
    Hesser, Hugo
    et al.
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedman-Lagerlöf, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Andersson, Erik
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, Perjohan
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Ljótsson, Brjánn
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    How does exposure therapy work? A comparison between generic and gastrointestinal anxiety-specific mediators in a dismantling study of exposure therapy for irritable bowel syndrome2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 3, p. 254-267Article in journal (Refereed)
    Abstract [en]

    Objective: Systematic exposure is potentially an effective treatment procedure for treating irritable bowel syndrome (IBS), but little is known about the processes by which it achieves its effect on outcome. The aim of this study was to identify mediators in a previously published randomized dismantling trial in which participants with IBS were randomized to Internet-delivered cognitive–behavioral treatment (ICBT) that incorporated systematic exposure or to the same treatment protocol without exposure (ICBT-WE).

    Method: Weekly measurements of gastrointestinal anxiety–specific process variables (behavioral avoidance, gastrointestinal-specific anxiety) based on the gastrointestinal symptom–specific anxiety model, generic process variables (self-efficacy and mindful nonreactivity), and treatment outcome (IBS symptoms) were obtained from 309 participants with IBS. Growth models and cross-lagged panel models, estimated within structural equation modeling, were employed to evaluate mediators of outcome.

    Results: Parallel process growth modeling showed that behavioral avoidance, gastrointestinal-specific anxiety, self-efficacy mediated the incremental effect of ICBT compared to ICBT-WE. The mediated effect of avoidance was stronger for individuals scoring high on the avoidance variable at 1st measurement point. Cross-lagged regression analyses with random effects revealed that behavioral avoidance and gastrointestinal-specific anxiety had a stronger effect on subsequent symptom change rather than vice versa, whereas mindful nonreactivity and self-efficacy displayed the opposite pattern.

    Conclusions: The evidence collectively provided support for the hypothesis that exposure for IBS achieves its positive results by virtue of changing gastrointestinal anxiety–specific processes rather than generic processes. IBS-specific behavioral avoidance emerged as the most clear-cut mediator of the specific effect of exposure on outcome.

  • 25. Kaldo, Viktor
    et al.
    Ramnerö, Jonas
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Jernelöv, Susanna
    Involving clients in treatment methods: A neglected interaction in the therapeutic relationship2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 6, p. 1136-1141Article in journal (Refereed)
    Abstract [en]

    Objective: The authors investigate a model on how clients’ differential involvement in therapeutic methods mediates the effect of therapist support in psychological treatment—in this case, a cognitive behaviorally based bibliotherapy for insomnia, administered with or without supportive telephone calls. Method: Eighty-nine participants, who fulfilled diagnostic criteria for insomnia, had a mean age of 49.1 years (range, 18–73 years) and were predominantly female (77%), fairly well educated, and mainly Caucasian. Participants were randomized between a bibliotherapeutic self-help treatment and the same treatment with the addition of therapist support. Primary outcome measure was the Insomnia Severity Index. Data on involvement in different methods and aspects of the treatment were estimated by clients at posttreatment and validated against therapist ratings of client involvement during treatment. Structural equation modeling was used to test if the effect of therapeutic support on outcome was mediated by involvement in treatment. Results: Carrying out the treatment with therapist support significantly boosted the therapeutic effects. A mediational analysis with involvement in the three key treatment methods (sleep restriction, sleep compression, and stimulus control) as the mediator fully mediated the differential effect between the two conditions (Sobel test; r = .31; z = 2.173; p < .05) and explained 68.4% of the total effect. Conclusions: Therapeutic support improved outcome via higher patient involvement rather than having a direct effect on outcome. Thus, relationship and methods could be regarded as interactional, and patient involvement should be considered. These factors could be further studied in treatments where specific ingredients within the therapeutic contact can be experimentally manipulated.

  • 26.
    Kaldo, Viktor
    et al.
    Karolinska Institutet.
    Ramnerö, Jonas
    Stockholm University.
    Jernelöv, Susanna
    Karolinska Institutet.
    Involving clients in treatment methods: A neglected interaction in the therapeutic relationship2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 6, p. 1136-1141, article id 2015-30577-001Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    The authors investigate a model on how clients' differential involvement in therapeutic methods mediates the effect of therapist support in psychological treatment-in this case, a cognitive behaviorally based bibliotherapy for insomnia, administered with or without supportive telephone calls.

    METHOD:

    Eighty-nine participants, who fulfilled diagnostic criteria for insomnia, had a mean age of 49.1 years (range, 18-73 years) and were predominantly female (77%), fairly well educated, and mainly Caucasian. Participants were randomized between a bibliotherapeutic self-help treatment and the same treatment with the addition of therapist support. Primary outcome measure was the Insomnia Severity Index. Data on involvement in different methods and aspects of the treatment were estimated by clients at posttreatment and validated against therapist ratings of client involvement during treatment. Structural equation modeling was used to test if the effect of therapeutic support on outcome was mediated by involvement in treatment.

    RESULTS:

    Carrying out the treatment with therapist support significantly boosted the therapeutic effects. A mediational analysis with involvement in the three key treatment methods (sleep restriction, sleep compression, and stimulus control) as the mediator fully mediated the differential effect between the two conditions (Sobel test; r = .31; z = 2.173; p < .05) and explained 68.4% of the total effect.

    CONCLUSIONS:

    Therapeutic support improved outcome via higher patient involvement rather than having a direct effect on outcome. Thus, relationship and methods could be regarded as interactional, and patient involvement should be considered. These factors could be further studied in treatments where specific ingredients within the therapeutic contact can be experimentally manipulated.

  • 27.
    Kessler, Henrik
    et al.
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Holmes, Emily A.
    Karolinska Inst, Dept Clin Neurosci, Solna, Sweden.
    Blackwell, Simon E.
    Ruhr Univ Bochum, Fac Psychol, Mental Hlth Res & Treatment Ctr, Bochum, Germany.
    Schmidt, Anna-Christine
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Schweer, Johanna M.
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Buecker, Anna
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Herpertz, Stephan
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Axmacher, Nikolai
    Ruhr Univ Bochum, Fac Psychol, Inst Cognit Neurosci, Dept Neuropsychol, Bochum, Germany.
    Kehyayan, Aram
    Ruhr Univ Bochum, LWL Univ Hosp, Dept Psychosomat Med & Psychotherapy, Alexandrinenstr 1-3, D-44791 Bochum, Germany.
    Reducing Intrusive Memories of Trauma Using a Visuospatial Interference Intervention With Inpatients With Posttraumatic Stress Disorder (PTSD)2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 12, p. 1076-1090Article in journal (Refereed)
    Abstract [en]

    Objective: The core clinical feature of posttraumatic stress disorder (PTSD) is recurrent intrusive memories of trauma. This study aimed to test a novel and simple intervention, inspired by the concepts of concurrent task interference and memory reconsolidation, to reduce the occurrence of intrusive memories among inpatients with complex PTSD. Method: In this open-label single case series 20 patients with longstanding complex PTSD in inpatient treatment monitored the occurrence of intrusive trauma memories (intrusions) over the course of their admission (5 to 10 weeks). Patients received study-specific intervention sessions (including a memory reminder for a specific intrusion then 25 min Tetris gameplay) on a weekly basis. A within-subjects multiple baseline AB design was used, in that the length of baseline ("A," preintervention, monitoring only) and postintervention ("B") phases varied within-subjects across individual intrusions. Further, some intrusions were never targeted by the intervention. The study was registered prior to analysis, ISRCTN34320836. Results: Frequency of targeted intrusions reduced by on average 64% from baseline to the postintervention phase. Conversely, never-targeted intrusions reduced in frequency by on average 11% over a comparable time-period. Of the 20 patients, 16 met our criteria for showing "response" to the intervention. Conclusions: Results provide initial evidence that this brief behavioral procedure might reduce the occurrence of intrusive traumatic memories in longstanding and complex PTSD, here delivered in an inpatient setting. The potential of this simple, focused intervention opens up new possibilities for tackling a core clinical symptom of PTSD, warranting further research.

  • 28.
    Käll, Anton
    et al.
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Shafran, Roz
    UCL Great Ormond St Inst Child Hlth, England.
    Lindegaard, Tomas
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Bennett, Sophie
    UCL Great Ormond St Inst Child Hlth, England.
    Cooper, Zafra
    Univ Oxford, England; Yale Univ, CT 06520 USA.
    Coughtrey, Anna
    UCL Great Ormond St Inst Child Hlth, England.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Region Östergötland, Anaesthetics, Operations and Specialty Surgery Center, Department of Otorhinolaryngology. Karolinska Inst, Sweden.
    A Common Elements Approach to the Development of a Modular Cognitive Behavioral Theory for Chronic Loneliness2020In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 88, no 3, p. 269-282Article in journal (Refereed)
    Abstract [en]

    Background: Loneliness is a transdiagnostic clinical phenomenon that can significantly impact mental health and well-being across the lifespan. Objective: The aim was to combine existing theory and evidence-based treatment approaches to propose a comprehensive transdiagnostic cognitive-behavioral analysis of the maintenance of chronic loneliness relevant across disorders, age groups, and populations. Method: A distillation and matching model-framework approach was taken to identify interventions designed to reduce loneliness. Eligible studies were coded for the presence of practice elements. The findings were combined with an analysis of the broader literature on loneliness and psychopathology to derive a comprehensive cognitive-behavioral analysis of the maintenance of loneliness over time across populations. Results: The search yielded 11 studies containing 14 practice elements with relative frequencies ranging from 7% to 64%. The identified practice elements target putative mechanisms such as negative interpersonal appraisals. anxiety, and social skills deficits. Counterproductive behavior and cognitive processes such as sell-focused attention were identified as maintenance factors based on the broader literature. A modular transdiagnostic model with multiple pathways is proposed to be consistent with the existing theoretical and treatment literature. Conclusions: Combining the distillation and matching model framework with existing theory from the literature is a novel approach for developing a model of factors that maintain loneliness over time. The model has varying treatment implications for different populations including children with autism spectrum disorders and bereaved older adults. Targeting transdiagnostic processes has the potential to transform interventions for loneliness across a range of formats and settings.

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  • 29. Ljotsson, Brjann
    et al.
    Hesser, Hugo
    Andersson, Erik
    Lindfors, Perjohan
    Hursti, Timo
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Ruck, Christian
    Lindefors, Nils
    Andersson, Gerhard
    Hedman, Erik
    Mechanisms of Change in an Exposure-Based Treatment for Irritable Bowel Syndrome2013In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 81, no 6, p. 1113-1126Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to identify mediators of change in a previously published randomized controlled trial that compared Internet-delivered cognitive behavioral treatment based on exposure exercises (ICBT) with Internet-delivered stress management (ISM) for irritable bowel syndrome (IBS). ICBT and ISM targeted distinct proposed mechanisms of illness maintenance and symptom exacerbation, gastrointestinal symptom-specific anxiety (GSA), and stress reactivity, respectively. The original study found that ICBT was more effective than ISM in improving IBS symptoms. Method: Weekly measurements of GSA and stress reactivity (putative mediators) and treatment outcome were obtained from 195 participants with IBS, who had been randomized to ICBT or ISM. Results: Parallel process growth mediational analyses revealed that the larger reduction of IBS symptoms from ICBT compared to ISM was mediated by changes in GSA, alpha beta = 0.42, 95% CIasymmetric [-0.71, -0.16]. In contrast, changes in stress reactivity did not mediate the difference in outcomes between treatments, alpha beta = 0.04, 95% CIasymmetric [-0.09, 0.20]. Analyses of the temporal sequence of week-to-week changes in process and outcome measures showed that only GSA displayed a pattern consistent with a causal model in which change in process preceded and contributed to symptom change. Furthermore, engagement in treatment specific activities was related to change in GSA but not to stress reactivity in the ICBT arm, whereas treatment specific activities were not related to change in any of the putative processes in the ISM arm. Conclusions: We conclude that ICBT works through directly targeting GSA, rather than by means of reducing stress reactivity.

  • 30.
    Ljótsson, B.
    et al.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Andersson, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Lindfors, P.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Gastroenterology, Sabbatsbergs Hospital, Stockholm, Sweden.
    Hursti, T.
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    Rück, C.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Lindefors, N.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Andersson, G.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden; Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden.
    Hedman, E.
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Mechanisms of change in an exposure-based treatment for irritable bowel syndrome2013In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 81, no 6, p. 1113-1126Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to identify mediators of change in a previously published randomized controlled trial that compared Internet-delivered cognitive behavioral treatment based on exposure exercises (ICBT) with Internet-delivered stress management (ISM) for irritable bowel syndrome (IBS). ICBT and ISM targeted distinct proposed mechanisms of illness maintenance and symptom exacerbation, gastrointestinal symptom-specific anxiety (GSA), and stress reactivity, respectively. The original study found that ICBT was more effective than ISM in improving IBS symptoms.

    Method: Weekly measurements of GSA and stress reactivity (putative mediators) and treatment outcome were obtained from 195 participants with IBS, who had been randomized to ICBT or ISM.

    Results: Parallel process growth mediational analyses revealed that the larger reduction of IBS symptoms from ICBT compared to ISM was mediated by changes in GSA, alpha beta = 0.42, 95% CIasymmetric [-0.71, -0.16]. In contrast, changes in stress reactivity did not mediate the difference in outcomes between treatments, alpha beta = 0.04, 95% CIasymmetric [-0.09, 0.20]. Analyses of the temporal sequence of week-to-week changes in process and outcome measures showed that only GSA displayed a pattern consistent with a causal model in which change in process preceded and contributed to symptom change. Furthermore, engagement in treatment specific activities was related to change in GSA but not to stress reactivity in the ICBT arm, whereas treatment specific activities were not related to change in any of the putative processes in the ISM arm.

    Conclusions: We conclude that ICBT works through directly targeting GSA, rather than by means of reducing stress reactivity.

  • 31.
    Ljótsson, Brjánn
    et al.
    Karolinska Institutet, Stockholm, Sweden.
    Hesser, Hugo
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Andersson, Erik
    Karolinska Institutet, Stockholm, Sweden.
    Lindfors, Perjohan
    Sabbatsbergs Hospital, Stockholm, Sweden.
    Hursti, Timo
    Uppsala University, Sweden.
    Rück, Christian
    Karolinska Institutet, Stockholm, Sweden.
    Lindefors, Nils
    Karolinska Institutet, Stockholm, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Hedman, Erik
    Karolinska Institutet, Stockholm, Sweden.
    Mechanisms of Change in an Exposure-Based Treatment for Irritable Bowel Syndrome2013In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 81, no 6, p. 1113-1126Article in journal (Refereed)
    Abstract [en]

    Objective: The aim of this study was to identify mediators of change in a previously published randomized controlled trial that compared Internet-delivered cognitive behavioral treatment based on exposure exercises (ICBT) with Internet-delivered stress management (ISM) for irritable bowel syndrome (IBS). ICBT and ISM targeted distinct proposed mechanisms of illness maintenance and symptom exacerbation, gastrointestinal symptom-specific anxiety (GSA), and stress reactivity, respectively. The original study found that ICBT was more effective than ISM in improving IBS symptoms.

    Method: Weekly measurements of GSA and stress reactivity (putative mediators) and treatment outcome were obtained from 195 participants with IBS, who had been randomized to ICBT or ISM.

    Results: Parallel process growth mediational analyses revealed that the larger reduction of IBS symptoms from ICBT compared to ISM was mediated by changes in GSA, αβ = -0.42, 95% CIasymmetric [-0.71, -0.16]. In contrast, changes in stress reactivity did not mediate the difference in outcomes between treatments, αβ = 0.04, 95% CIasymmetric [-0.09, 0.20]. Analyses of the temporal sequence of week-to-week changes in process and outcome measures showed that only GSA displayed a pattern consistent with a causal model in which change in process preceded and contributed to symptom change. Furthermore, engagement in treatment specific activities was related to change in GSA but not to stress reactivity in the ICBT arm, whereas treatment specific activities were not related to change in any of the putative processes in the ISM arm.

    Conclusions: We conclude that ICBT works through directly targeting GSA, rather than by means of reducing stress reactivity. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

  • 32.
    Magnusson, Kristoffer
    et al.
    Karolinska Inst, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences.
    Carlbring, Per
    Stockholm Univ, Sweden.
    The Consequences of Ignoring Therapist Effects in Trials With Longitudinal Data: A Simulation Study2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 9, p. 711-725Article in journal (Refereed)
    Abstract [en]

    Objective: Psychotherapy trials frequently generate multilevel longitudinal data with 3 levels. This type of hierarchy exists in all trials in which therapists deliver the treatment and patients are repeatedly measured. Unfortunately, researchers often ignore the possibility that therapists could differ in their performance and instead assume there is no difference between therapists in their average impact on patients rate of change. In this article, we focus on scenarios in which therapists are fully and partially nested within treatments and investigate the consequences of ignoring even small therapist effects in longitudinal data. Method: We first derived the factors leading to increased Type I errors for the Time x Treatment effect in a balanced study. Scenarios with an unbalanced allocation of patients to therapists and studies with missing data were then investigated in a comprehensive simulation study, in which the correct 3-level linear mixed-effects model, which modeled therapist effects using a random slope at the therapist level, was compared with a misspecified 2-level model. Results: Type I errors were strongly influenced by several interacting factors. Estimates of the therapist-level random slope suffer from bias when there are very few therapists per treatment. Conclusion: Researchers should account for therapist effects in the rate of change in longitudinal studies. To facilitate this, we developed an open source R package powerlmm, which makes it easy to investigate model misspecification and conduct power analysis for these designs.

  • 33. Magnusson, Kristoffer
    et al.
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    The Consequences of Ignoring Therapist Effects in Trials With Longitudinal Data: A Simulation Study2018In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 86, no 9, p. 711-725Article in journal (Refereed)
    Abstract [en]

    Objective: Psychotherapy trials frequently generate multilevel longitudinal data with 3 levels. This type of hierarchy exists in all trials in which therapists deliver the treatment and patients are repeatedly measured. Unfortunately, researchers often ignore the possibility that therapists could differ in their performance and instead assume there is no difference between therapists in their average impact on patients' rate of change. In this article, we focus on scenarios in which therapists are fully and partially nested within treatments and investigate the consequences of ignoring even small therapist effects in longitudinal data.

    Method: We first derived the factors leading to increased Type I errors for the Time x Treatment effect in a balanced study. Scenarios with an unbalanced allocation of patients to therapists and studies with missing data were then investigated in a comprehensive simulation study, in which the correct 3-level linear mixed-effects model, which modeled therapist effects using a random slope at the therapist level, was compared with a misspecified 2-level model.

    Results: Type I errors were strongly influenced by several interacting factors. Estimates of the therapist-level random slope suffer from bias when there are very few therapists per treatment.

    Conclusion: Researchers should account for therapist effects in the rate of change in longitudinal studies. To facilitate this, we developed an open source R package powerlmm, which makes it easy to investigate model misspecification and conduct power analysis for these designs.

  • 34. Magnusson, Kristoffer
    et al.
    Nilsson, Anders
    Andersson, Gerhard
    Hellner, Clara
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology. University of Southern Denmark, Denmark.
    Internet-Delivered Cognitive-Behavioral Therapy for Significant Others of Treatment-Refusing Problem Gamblers: A Randomized Wait-List Controlled Trial2019In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 87, no 9, p. 802-814Article in journal (Refereed)
    Abstract [en]

    Objective: Problem gambling can cause severe harm to concerned significant others (CSOs) in the form of, for example, relationship problems, financial difficulties, and mental and physical illness. CSOs are important for their ability to support problem gamblers and motivate them to change. This study investigated the effect of an Internet-based intervention for CSOs of treatment-refusing problem gamblers on (a) gambling-related harm, (b) the gamblers' treatment-seeking rate, and (c) the relationship satisfaction and mental health of the CSOs. Method: A total of 100 CSOs of problem gamblers were randomized into one of two conditions: Internet-delivered cognitive-behavioral therapy for CSOs or a wait-list control group. The intervention group was given Internet-based treatment consisting of nine modules with therapist support available via telephone and e-mail. Outcome measures were collected up 12 months posttreatment. Results: The intervention improved the psychological well-being of the CSOs compared to the wait-list group at the posttest (CSO's emotional consequences: d = -0.90, 95% CI [-1.47, -0.33]; relationship satisfaction: d = 0.41, 95% CI [0.05, 0.76]; anxiety: d = -0.45, 95% CI [-0.81, -0.09]; depression: d = -0.49, 95% CI [-0.82, -0.16]). However, the effects on the gambling outcomes were small and inconclusive (gambling losses: multiplicative effect -0.73, 95% CI [0.29, 1.85]; treatment-seeking: hazard ratio = 0.86, 95% CI [0.31, 2.38]). Conclusion: The results confirm earlier studies' findings that affecting the gambler via a CSO is challenging, but it is possible to increase the CSO's coping and well-being. The trial's outcome data and scripts are available for download (https://osf. io/awtg7/).

  • 35.
    Magnusson, Kristoffer
    et al.
    Karolinska Inst, Sweden.
    Nilsson, Anders
    Karolinska Inst, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Inst, Sweden.
    Hellner, Clara
    Karolinska Inst, Sweden.
    Carlbring, Per
    Stockholm Univ, Sweden; Univ Southern Denmark, Denmark.
    Internet-Delivered Cognitive-Behavioral Therapy for Significant Others of Treatment-Refusing Problem Gamblers: A Randomized Wait-List Controlled Trial2019In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 87, no 9, p. 802-814Article in journal (Refereed)
    Abstract [en]

    Objective: Problem gambling can cause severe harm to concerned significant others (CSOs) in the form of, for example, relationship problems, financial difficulties, and mental and physical illness. CSOs are important for their ability to support problem gamblers and motivate them to change. This study investigated the effect of an Internet-based intervention for CSOs of treatment-refusing problem gamblers on (a) gambling-related harm, (b) the gamblers’ treatment-seeking rate, and (c) the relationship satisfaction and mental health of the CSOs. 

    Method: A total of 100 CSOs of problem gamblers were randomized into one of two conditions: Internet-delivered cognitive–behavioral therapy for CSOs or a wait-list control group. The intervention group was given Internet-based treatment consisting of nine modules with therapist support available via telephone and e-mail. Outcome measures were collected up 12 months posttreatment. 

    Results: The intervention improved the psychological well-being of the CSOs compared to the wait-list group at the posttest (CSO’s emotional consequences: d= −0.90, 95% CI [−1.47, −0.33]; relationship satisfaction: d = 0.41, 95% CI [0.05, 0.76]; anxiety: d = −0.45, 95% CI [−0.81, −0.09]; depression: d = −0.49, 95% CI [−0.82, −0.16]). However, the effects on the gambling outcomes were small and inconclusive (gambling losses: multiplicative effect = 0.73, 95% CI [0.29, 1.85]; treatment-seeking: hazard ratio = 0.86, 95% CI [0.31, 2.38]). 

    Conclusion: The results confirm earlier studies’ findings that affecting the gambler via a CSO is challenging, but it is possible to increase the CSO’s coping and well-being. The trial’s outcome data and scripts are available for download (https://osf.io/awtg7/).

  • 36. Ollendick, Thomas, H.
    et al.
    Öst, Lars-Göran
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Reuterskiöld, Lena
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Costa, Natalie
    Cederlund, Rio
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Sirbu, Cristian
    Davis, Thompson E., III
    Jarrett, Mathew, A.
    One-Session Treatment of Specific Phobias in Youth: A Randomized Clinical Trial in the United States and Sweden2009In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 77, no 3, p. 504-509Article in journal (Refereed)
    Abstract [en]

    One hundred and ninety-six youth, ages 7–16, who fulfilled Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for various specific phobias were randomized to a one-session exposure treatment, education support treatment, or a wait list control group. After the waiting period, the wait list participants were offered treatment and, if interested, rerandomized to 1 of the 2 active treatments. The phobias were assessed with semistructured diagnostic interviews, clinician severity ratings, and behavioral avoidance tests, whereas fears, general anxiety, depression, and behavior problems were assessed with self- and parent report measures. Assessments were completed pretreatment, posttreatment, and at 6 months following treatment. Results showed that both treatment conditions were superior to the wait list control condition and that 1-session exposure treatment was superior to education support treatment on clinician ratings of phobic severity, percentage of participants who were diagnosis free, child ratings of anxiety during the behavioral avoidance test, and treatment satisfaction as reported by the youth and their parents. There were no differences on self-report measures. Treatment effects were maintained at follow-up. Implications of these findings are discussed.

  • 37.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Forsell, Erik
    Svensson, Andreas
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology.
    Internet-based cognitive behavior therapy for procrastination: A randomized controlled trial2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 4, p. 808-824Article in journal (Refereed)
    Abstract [en]

    Objective: Procrastination can be a persistent behavior pattern associated with personal distress. However, research investigating different treatment interventions is scarce, and no randomized controlled trial has examined the efficacy of cognitive−behavior therapy (CBT). Meanwhile, Internet-based CBT has been found promising for several conditions, but has not yet been used for procrastination. Method: Participants (N = 150) were randomized to guided self-help, unguided self-help, and wait-list control. Outcome measures were administered before and after treatment, or weekly throughout the treatment period. They included the Pure Procrastination Scale, the Irrational Procrastination Scale, the Susceptibility to Temptation Scale, the Montgomery Åsberg Depression Rating Scale−Self-report version, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory. The intention-to-treat principle was used for all statistical analyses. Results: Mixed-effects models revealed moderate between-groups effect sizes comparing guided and unguided self-help with wait-list control; the Pure Procrastination Scale, Cohen’s d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the Irrational Procrastination Scale, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3–40.0% for guided self-help, compared with 24.0–36.0% for unguided self-help. Neither of the treatment conditions was found to be superior on any of the outcome measures, Fs(98, 65.17−72.55)< 1.70, p >.19. Conclusion: Internet-based CBT could be useful for managing self-reported difficulties due to procrastination, both with and without the guidance of a therapist.

  • 38.
    Rozental, Alexander
    et al.
    Stockholm University, Sweden.
    Forsell, Erik
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Psychology.
    Svensson, Andreas
    Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Behavioural Sciences and Learning, Psychology.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institute, Sweden.
    Carlbring, Per
    Stockholm University, Sweden.
    Internet-Based Cognitive-Behavior Therapy for Procrastination: A Randomized Controlled Trial2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 4, p. 808-824Article in journal (Refereed)
    Abstract [en]

    Objective: Procrastination can be a persistent behavior pattern associated with personal distress. However, research investigating different treatment interventions is scarce, and no randomized controlled trial has examined the efficacy of cognitive-behavior therapy (CBT). Meanwhile, Internet-based CBT has been found promising for several conditions, but has not yet been used for procrastination. Method: Participants (N = 150) were randomized to guided self-help, unguided self-help, and wait-list control. Outcome measures were administered before and after treatment, or weekly throughout the treatment period. They included the Pure Procrastination Scale, the Irrational Procrastination Scale, the Susceptibility to Temptation Scale, the Montgomery sberg Depression Rating Scale-Self-report version, the Generalized Anxiety Disorder Assessment, and the Quality of Life Inventory. The intention-to-treat principle was used for all statistical analyses. Results: Mixed-effects models revealed moderate between-groups effect sizes comparing guided and unguided self-help with wait-list control; the Pure Procrastination Scale, Cohens d = 0.70, 95% confidence interval (CI) [0.29, 1.10], and d = 0.50, 95% CI [0.10, 0.90], and the Irrational Procrastination Scale, d = 0.81 95% CI [0.40, 1.22], and d = 0.69 95% CI [0.29, 1.09]. Clinically significant change was achieved among 31.3-40.0% for guided self-help, compared with 24.0-36.0% for unguided self-help. Neither of the treatment conditions was found to be superior on any of the outcome measures, Fs(98, 65.17-72.55) less than 1.70, p greater than .19. Conclusion: Internet-based CBT could be useful for managing self-reported difficulties due to procrastination, both with and without the guidance of a therapist.

  • 39.
    Rozental, Alexander
    et al.
    Division of Clinical Psychology, Karolinska Institutet, Sweden.
    Magnusson, Kristoffer
    Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet..
    Boettcher, Johanna
    Department of Clinical Psychology and Psychotherapy, Freie Universität Berlin, Germany.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Psychology. Linköping University, Faculty of Arts and Sciences. Division of Psychiatry, Department of Clinical Neuroscience, Karolinska Institutet, Sweden.
    Carlbring, Per
    Division of Clinical Psychology, Karolinska Institutet, Sweden.
    For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy.2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 2, p. 160-177Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive-behavioral therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking.

    METHOD: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2,866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation.

    RESULTS: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, odds ratios (ORs) = 3.10, 95% confidence interval (CI) [2.21, 4.34]. Clinical severity at pretreatment was related to lower odds, OR = 0.62, 95% CI [0.50, 0.77], and OR = 0.51, 95% CI [0.51, 0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, OR = 0.58, 95% CI [0.35, 0.95], having at least a university degree, OR = 0.54, 95% CI [0.33, 0.88], and being older, OR = 0.78, 95% CI, [0.62, 0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition.

    CONCLUSION: Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers to reverse and prevent a negative treatment trend. (PsycINFO Database Record

  • 40.
    Rozental, Alexander
    et al.
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    Magnusson, Kristoffer
    Boettcher, Johanna
    Andersson, Gerhard
    Carlbring, Per
    Stockholm University, Faculty of Social Sciences, Department of Psychology, Clinical psychology.
    For Better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapy2017In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 85, no 2, p. 160-177Article in journal (Refereed)
    Abstract [en]

    Objective: Psychological treatments can relieve mental distress and improve well-being, and the dissemination of evidence-based methods can help patients gain access to the right type of aid. Meanwhile, Internet-based cognitive–behavioral therapy (ICBT) has shown promising results for many psychiatric disorders. However, research on the potential for negative effects of psychological treatments has been lacking. Method: An individual patient data meta-analysis of 29 clinical trials of ICBT (N = 2,866) was performed using the Reliable Change Index for each primary outcome measures to distinguish deterioration rates among patients in treatment and control conditions. Statistical analyses of predictors were conducted using generalized linear mixed models. Missing data was handled by multiple imputation. Results: Deterioration rates were 122 (5.8%) in treatment and 130 (17.4%) in control conditions. Relative to receiving treatment, patients in a control condition had higher odds of deteriorating, odds ratios (ORs) = 3.10, 95% confidence interval (CI) [2.21, 4.34]. Clinical severity at pretreatment was related to lower odds, OR = 0.62, 95% CI [0.50, 0.77], and OR = 0.51, 95% CI [0.51, 0.80], for treatment and control conditions. In terms of sociodemographic variables, being in a relationship, OR = 0.58, 95% CI [0.35, 0.95], having at least a university degree, OR = 0.54, 95% CI [0.33, 0.88], and being older, OR = 0.78, 95% CI, [0.62, 0.98], were also associated with lower odds of deterioration, but only for patients assigned to a treatment condition. Conclusion: Deterioration among patients receiving ICBT or being in a control condition can occur and should be monitored by researchers to reverse and prevent a negative treatment trend.

  • 41.
    Stattin, Håkan
    et al.
    Univ Orebro, Sch Law Psychol & Social Work, Youth & Soc, SE-70182 Orebro, Sweden..
    Enebrink, Pia
    Karolinska Inst, Div Psychol, Dept Clin Neurosci, S-10401 Stockholm, Sweden..
    Ozdemir, Metin
    Univ Orebro, Sch Law Psychol & Social Work, Youth & Soc, SE-70182 Orebro, Sweden..
    Giannotta, Fabrizia
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    A National Evaluation of Parenting Programs in Sweden: The Short-Term Effects Using an RCT Effectiveness Design2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 6, p. 1069-1084Article in journal (Refereed)
    Abstract [en]

    Objective: We evaluated the effectiveness of 4 parent-training programs for children with externalizing problems. We tested the effectiveness of 3 behavioral programs (Comet, Cope, and Incredible Years) and 1 nonbehavioral program (Connect) in reducing child behavior problems and attention-deficit/ hyperactivity disorder (ADHD) symptoms, in improving positive parenting and parenting competence, and in decreasing negative parenting and parents' stress and depressive symptoms. Method: This national study was designed as a randomized-controlled effectiveness trial (RCT). The treatments were carried out in 30 clinical and community-based practices. Parents of 908 children (ages 3-12 years) were randomly assigned to 1 of 2 parent training programs available at each practice, or to a wait-list condition, where parents had sought help from regular services. Before and after treatment, parents rated child behavior problems and parenting strategies. Results: At posttreatment, children whose parents had received interventions showed a strong decrease in child conduct problems and a moderate to strong decrease in ADHD symptoms. About half of parents whose children scored over the 95th percentile on the behavior measures (Eyberg Child Behavior Inventory, Swanson, Nolan, and Pelham Rating Scale), a clinically meaningful cutoff, reported that their children were no longer above the cutoff after the intervention. Parents showed considerably less negative behaviors toward their children at posttest compared with pretest; they increased in parental competence, and decreased in both stress and depressive symptoms. Overall, the behavioral programs were more effective than the nonbehavioral program. Conclusions: The results support the general efficacy of parent training in a short-term perspective.

  • 42.
    Stattin, Håkan
    et al.
    Örebro University, School of Law, Psychology and Social Work.
    Enebrink, Pia
    Department of Clinical Neuroscience, Division of Psychology, Karolinska Institutet, Stockholm, Sweden.
    Özdemir, Metin
    Örebro University, School of Law, Psychology and Social Work.
    Giannotta, Fabrizia
    Department of Psychology, Uppsala University, Uppsala, Sweden.
    A National Evaluation of Parenting Programs in Sweden: The Short-Term Effects Using an RCT Effectiveness Design2015In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 83, no 6, p. 1069-1084Article in journal (Refereed)
    Abstract [en]

    Objective: We evaluated the effectiveness of 4 parent-training programs for children with externalizing problems. We tested the effectiveness of 3 behavioral programs (Comet, Cope, and Incredible Years) and 1 nonbehavioral program (Connect) in reducing child behavior problems and attention-deficit/hyperactivity disorder (ADHD) symptoms, in improving positive parenting and parenting competence, and in decreasing negative parenting and parents’ stress and depressive symptoms.

    Method: This national study was designed as a randomized-controlled effectiveness trial (RCT). The treatments were carried out in 30 clinical and community-based practices. Parents of 908 children (ages 3–12 years) were randomly assigned to 1 of 2 parent training programs available at each practice, or to a wait-list condition, where parents had sought help from regular services. Before and after treatment, parents rated child behavior problems and parenting strategies.

    Results: At posttreatment, children whose parents had received interventions showed a strong decrease in child conduct problems and a moderate to strong decrease in ADHD symptoms. About half of parents whose children scored over the 95th percentile on the behavior measures (Eyberg Child Behavior Inventory, Swanson, Nolan, and Pelham Rating Scale), a clinically meaningful cutoff, reported that their children were no longer above the cutoff after the intervention. Parents showed considerably less negative behaviors toward their children at posttest compared with pretest; they increased in parental competence, and decreased in both stress and depressive symptoms. Overall, the behavioral programs were more effective than the nonbehavioral program.

    Conclusions: The results support the general efficacy of parent training in a short-term perspective.

  • 43.
    Ström, Lars
    et al.
    Department of Psychology, University of Uppsala, Uppsala, Sweden.
    Pettersson, Richard
    Department of Psychology, University of Uppsala, Uppsala, Sweden.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Internet-Based Treatment for Insomnia: A Controlled Evaluation2004In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 72, no 1, p. 113-120Article in journal (Refereed)
    Abstract [en]

    This study investigated the effects of an Internet-based intervention for insomnia. Participants who met criteria for insomnia (N = 109) were randomly assigned to either a cognitive-behavioral self-help treatment or a waiting list control condition. The 5-week intervention mainly consisted of sleep restriction, stimulus control, and cognitive restructuring. Sleep diary data were collected for 2 weeks at baseline and at posttreatment. The dropout rate was 24% (n = 28). Results showed statistically significant improvements in the treatment group on many outcome measures, including total sleep time, total wake time in bed, and sleep efficiency. However, improvements were also found in the control group. Overall, between-groups effect sizes were low, with the exception of the Beliefs and Attitudes About Sleep Scale (Cohen's d = .81).

  • 44.
    Ström, Lars
    et al.
    Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Psychology.
    Pettersson, Richard
    Andersson, Gerhard
    Internet-based treatment for insomnia: A controlled evaluation2004In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 72, no 1, p. 113-120Article in journal (Refereed)
    Abstract [en]

    This study investigated the effects of an Internet-based intervention for insomnia. Participants who met criteria for insomnia (N = 109) were randomly assigned to either a cognitive-behavioral self-help treatment or a waiting list control condition. The 5-week intervention mainly consisted of sleep restriction, stimulus control, and cognitive restructuring. Sleep diary data were collected for 2 weeks at baseline and at posttreatment. The dropout rate was 24% (n = 28). Results showed statistically significant improvements in the treatment group on many outcome measures, including total sleep time, total wake time in bed, and sleep efficiency. However, improvements were also found in the control group. Overall, between-groups effect sizes were low, with the exception of the Beliefs and Attitudes About Sleep Scale (Cohen's d =.81).

  • 45.
    Weise, Cornelia
    et al.
    Philipps-Universität Marburg, Germany.
    Heinecke, Kristin
    Philipps-Universität Marburg, Germany.
    Rief, Winfried
    Philipps-Universität Marburg, Germany.
    Biofeedback-based behavioral treatment for chronic tinnitus: Results of a randomized controlled trial2008In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 76, no 6, p. 1046-1057Article in journal (Refereed)
    Abstract [en]

    Many tinnitus sufferers believe that their tinnitus has an organic basis and thus seek medical rather than psychological treatments. Tinnitus has been found to be associated with negative appraisal, dysfunctional attention shift, and heightened psychophysiological arousal, so cognitive-behavioral interventions and biofeedback are commonly suggested as treatments. This study developed and investigated the efficacy of a biofeedback-based cognitive-behavioral treatment for tinnitus. In total, 130 tinnitus patients were randomly assigned to an intervention or a wait-list control group. Treatment consisted of 12 sessions of a biofeedback-based behavioral intervention over a 3-month period. Patients in the wait-list group participated in the treatment after the intervention group had completed the treatment. Results showed clear improvements regarding tinnitus annoyance, diary ratings of loudness, and feelings of controllability. Furthermore, changes in coping cognitions as well as changes in depressive symptoms were found. Improvements were maintained over a 6-month follow-up period in which medium-to-large effect sizes were observed. The treatment developed and investigated in this study is well accepted and leads to clear and stable improvements. Through demonstration of psychophysiological interrelationships, the treatment enables patients to change their somatic illness perceptions to a more psychosomatic point of view. © 2008 American Psychological Association.

  • 46.
    Williams, Alishia D.
    et al.
    Univ New S Wales, Sch Psychiat, UNSW Med, Sydney, NSW, Australia;St Vincents Hosp, Clin Res Unit Anxiety & Depress CRUfAD, Sydney, NSW 2010, Australia.
    Blackwell, Simon E.
    MRC Cognit & Brain Sci Unit, Cambridge, England.
    Mackenzie, Anna
    St Vincents Hosp, CRUfAD, Sydney, NSW 2010, Australia.
    Holmes, Emily A.
    MRC Cognit & Brain Sci Unit, Cambridge, England.
    Andrews, Gavin
    Univ New S Wales, Sch Psychiat, UNSW Med, Sydney, NSW, Australia;St Vincents Hosp, CRUfAD, Sydney, NSW 2010, Australia.
    Combining Imagination and Reason in the Treatment of Depression: A Randomized Controlled Trial of Internet-Based Cognitive-Bias Modification and Internet-CBT for Depression2013In: Journal of Consulting and Clinical Psychology, ISSN 0022-006X, E-ISSN 1939-2117, Vol. 81, no 5, p. 793-799Article in journal (Refereed)
    Abstract [en]

    Objective: Computerized cognitive-bias modification (CBM) protocols are rapidly evolving in experimental medicine yet might best be combined with Internet-based cognitive behavioral therapy (iCBT). No research to date has evaluated the combined approach in depression. The current randomized controlled trial aimed to evaluate both the independent effects of a CBM protocol targeting imagery and interpretation bias (CBM-I) and the combined effects of CBM-I followed by iCBT. Method: Patients diagnosed with a major depressive episode were randomized to an 11-week intervention (1 week/CBM-I + 10 weeks/iCBT; n = 38) that was delivered via the Internet with no face-to-face patient contact or to a wait-list control (WLC; n = 31). Results: Intent-to-treat marginal models using restricted maximum likelihood estimation demonstrated significant reductions in primary measures of depressive symptoms and distress corresponding to medium-large effect sizes (Cohen's d = 0.62-2.40) following CBM-I and the combined (CBM-I + iCBT) intervention. Analyses demonstrated that the change in interpretation bias at least partially mediated the reduction in depression symptoms following CBM-I. Treatment superiority over the WLC was also evident on all outcome measures at both time points (Hedges gs = .59-.98). Significant reductions were also observed following the combined intervention on secondary measures associated with depression: disability, anxiety, and repetitive negative thinking (Cohen's d = 1.51-2.23). Twenty-seven percent of patients evidenced clinically significant change following CBM-I, and this proportion increased to 65% following the combined intervention. Conclusions: The current study provides encouraging results of the integration of Internet-based technologies into an efficacious and acceptable form of treatment delivery.

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