Dysfunctional cognition and self-efficacy as mediators of symptom change in exposure therapy for agoraphobia – Systematic review and meta-analysis

Self-Efficacy Effects on Symptom Experiences in Daily Life and Early Treatment Success in Anxiety Patients

Self-efficacy is a key construct in behavioral science affecting mental health and psychopathology. Here, we expand on previously demonstrated between-persons self-efficacy effects. We prompted 66 patients five times daily for 14 days before starting cognitive behavioral therapy (CBT) to provide avoidance, hope, and perceived psychophysiological-arousal ratings. Multilevel logistic regression analyses confirmed self-efficacy's significant effects on avoidance in daily life (odds ratio [OR] = 0.53, 95% confidence interval [CI] = [0.34, 0.84], p = .008) and interaction effects with anxiety in predicting perceived psychophysiological arousal (OR = 0.79, 95% CI = [0.62, 1.00], p = .046) and hope (OR = 1.21, 95% CI = [1.03, 1.42], p = .02). More self-efficacious patients also reported greater anxiety-symptom reduction early in treatment. Our findings assign a key role to self-efficacy for daily anxiety-symptom experiences and for early CBT success. Self-efficacy interventions delivered in patients' daily lives could help improve treatment outcome.

Cognitive Behavioral Therapy for Anxiety Disorders

Cognitive behavioral therapy (CBT) is the front-line psychological intervention for the treatment of anxiety disorders. It is based on the cognitive behavioral model of anxiety disorders, which conceptualizes anxiety as caused by a pattern of maladaptive cognitive appraisals and avoidance behaviors that perpetuate pathologic fears. CBT includes core components that are relevant across anxiety disorders, including psychoeducation, cognitive restructuring, exposure therapy, and relapse prevention. CBT has a strong evidence base supporting its short-term and long-term efficacy and effectiveness. A case vignette is provided to illustrate the application of CBT principles. Clinical complexities, clinical recommendations, and future research directions are discussed.

The social-cognitive clinician: On the implications of social cognitive theory for psychotherapy and assessment

We review Bandura's contributions to cognitive-behavioural theory, research and practice. His basic research on the causal role of cognitive processes in social learning was a major factor in the emergence of cognitive-behavioural therapies in the 1970s. His investigations on observational learning and self-efficacy beliefs led to the development of guided mastery therapy, a specific cognitive-behavioural intervention for anxiety disorders. His research on self-regulatory processes provided an empirical basis for the emergence of numerous therapies targeting self-regulation. We conclude by discussing how Bandura's social cognitive theory, as well as more recent advances in social cognitive theorising, might be further applied to innovative approaches to therapeutic interventions, assessment and clinical case conceptualization.

Mediators of outcome in adolescent psychotherapy and their implications for theories and mechanisms of change: a systematic review

Psychotherapeutic treatment of adolescents requires age-specific approaches and thus plausibly also involves different change mechanisms than adult psychotherapy. To guide further research and improve therapeutic outcomes for adolescents, we reviewed all RCTs investigating mechanisms of change in the psychological treatment of adolescents to identify the most promising age-, disorder- or treatment-specific mediators. Following the preferred reporting items for systematic reviews (PRISMA), 106 studies were included that reported 252 statistical mediation tests assessed with 181 different measures. Most often studied and significant mediators were cognitive, followed by family-related, and behavioral variables. Several mediators were identified to be promising for future investigations: changes in negative thoughts, dysfunctional beliefs and metacognitive skills; family functioning and parenting skills; as well as successful engagement in therapy activities and increased impulse control. Symptom change during therapy was least often a mediator for other therapeutic changes. Relational and emotional mediators were largely understudied, whereas peer-influence appeared a promising mediator for intervention outcomes. Adolescence-specific mediators were most commonly investigated. Majority of studied mediators were not disorder-specific. There was a tendency to mainly test change mechanisms of specific theoretical models without considering other possible change theories. Further, virtually no studies fulfilled all criteria for rigorously investigating mediation and only nine were classified with an overall good study quality. While bearing in mind the current limitations in study designs, methodological rigor and reporting, there appears to be substantial evidence for transdiagnostic age-specific change models in the psychological treatment of adolescents. For future research, need for consensus on a core set of transdiagnostic and transtheoretical mediators and measures is highlighted. These should address likely core mechanisms of change, as well as take into account age-relevant developmental challenges and biological markers.

An evaluation of nursing students' learning self-efficacy: A multi-dimensional instrument development and structural validation

BACKGROUND

Nursing learning self-efficacy (NLSE) is essential in nursing students' learning, and since it is a task-dependent construct, accurate measurements require a multidimensional instrument.

OBJECTIVE

This research aimed to develop and validate a multidimensional NLSE instrument to measure Taiwanese nursing students' views of nursing learning self-efficacy.

DESIGN

The cross-sectional study design was used for this investigation.

PARTICIPANTS

The study included 1143 nursing students from a nursing junior college.

METHODS

To assess the validity and reliability of the instrument's factors, exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were utilized. Conceptual understanding, higher-order cognitive skills, practical work, everyday application, and nursing communication were identified as five factors. A comparison of five proposed models was also conducted.

RESULTS

The study found that the correlated and one-factor second-order models were acceptable and provided a simple structure for evaluating nursing students' perceptions of NLSE. Furthermore, a specific model with two second-order scales (Cognition and Application) and one first-order scale (nursing communication) was identified, highlighting the crucial role of nursing communication in nursing students' self-efficacy.

CONCLUSIONS

Evaluating nursing students' learning self-efficacy using a valid and reliable instrument is crucial for understanding their learning confidence. The creation of such a scale constitutes the primary contribution of this study.

Effects of a brief online emotion word learning task on negative emotion differentiation, emotional self-efficacy, and prospective distress: Preliminary findings

BACKGROUND

Disruptions in emotion processing are common across psychological disorders. Research suggests that emotion differentiation (ED; specificity in language used to characterize one's emotional experience) and emotional self-efficacy (ESE; perceived ability to understand and manage one's emotions) are important transdiagnostic factors associated with various psychological benefits. Whether ED and ESE can be improved in adults remains largely unclear.

METHODS

Using a longitudinal prospective design, we tested a brief online training targeting emotion word knowledge (vs. a control condition) to see if it improved negative ED (NED) and ESE in a college sample. Moreover, we tested if changes in NED or ESE mediated the effects of the training on levels of psychological distress one week and two-months post-intervention.

RESULTS

Findings provided partial support for our hypotheses. Individuals whose ESE increased post-intervention reported lower levels of distress two months later. Moreover, exploratory analyses revealed those who demonstrated greater training engagement experienced increases in NED that in turn predicted lower distress one-week post-intervention. However, there were no direct effects of intervention group on NED or ESE and distress.

CONCLUSIONS

These findings highlight the potential of a remotely-administered emotion-language intervention to influence key dimensions of emotion processing and suggest avenues for further refinement. Both NED and ESE may be malleable for some, and that enhancements in ESE may produce long-term psychological benefits.

An exposure-based implementation strategy to decrease clinician anxiety about implementing suicide prevention evidence-based practices: protocol for development and pilot testing (Project CALMER)

BACKGROUND

Clinicians often report that their own anxiety and low self-efficacy inhibit their use of evidence-based suicide prevention practices, including gold-standard screening and brief interventions. Exposure therapy to reduce clinician maladaptive anxiety and bolster self-efficacy use is a compelling but untested approach to improving the implementation of suicide prevention evidence-based practices (EBPs). This project brings together an interdisciplinary team to leverage decades of research on behavior change from exposure theory to design and pilot test an exposure-based implementation strategy (EBIS) to target clinician anxiety to improve suicide prevention EBP implementation.

METHODS

We will develop, iteratively refine, and pilot test an EBIS paired with implementation as usual (IAU; didactic training and consultation) in preparation for a larger study of the effect of this strategy on reducing clinician anxiety, improving self-efficacy, and increasing use of the Columbia Suicide Severity Rating Scale and the Safety Planning Intervention in outpatient mental health settings. Aim 1 of this study is to use participatory design methods to develop and refine the EBIS in collaboration with a stakeholder advisory board. Aim 2 is to iteratively refine the EBIS with up to 15 clinicians in a pilot field test using rapid cycle prototyping. Aim 3 is to test the refined EBIS in a pilot implementation trial. Forty community mental health clinicians will be randomized 1:1 to receive either IAU or IAU + EBIS for 12 weeks. Our primary outcomes are EBIS acceptability and feasibility, measured through questionnaires, interviews, and recruitment and retention statistics. Secondary outcomes are the engagement of target implementation mechanisms (clinician anxiety and self-efficacy related to implementation) and preliminary effectiveness of EBIS on implementation outcomes (adoption and fidelity) assessed via mixed methods (questionnaires, chart-stimulated recall, observer-coded role plays, and interviews).

DISCUSSION

Outcomes from this study will yield insight into the feasibility and utility of directly targeting clinician anxiety and self-efficacy as mechanistic processes informing the implementation of suicide prevention EBPs. Results will inform a fully powered hybrid effectiveness-implementation trial to test EBIS' effect on implementation and patient outcomes.

TRIAL REGISTRATION

Clinical Trials Registration Number: NCT05172609 . Registered on 12/29/2021.

Moderators and mediators of change of an internet-based mindfulness intervention for college students: secondary analysis from a randomized controlled trial

Background

Existing evidence suggests internet- and mobile-based interventions (IMIs) improve depressive symptoms in college students effectively. However, there is far less knowledge about the potential mechanisms of change of mindfulness-based IMIs, which could contribute to optimizing target groups and interventions. Hence, within this secondary analysis of data from a randomized controlled trial (RCT), potential moderators and mediators of the effectiveness of the IMI StudiCare Mindfulness were investigated.

Methods

Moderation and mediation analyses were based on secondary data from a RCT that examined the effectiveness of the 7-module IMI StudiCare Mindfulness in a sample of college students (intervention group: n = 217; waitlist control group: n = 127). Assessments were collected before (t0; baseline), 4 weeks after (t1; during intervention), and 8 weeks after (t2; post-intervention) randomization. Longitudinal mediation analyses using structural equation modeling were employed, with depressive symptom severity as the dependent variable. For moderation analyses, bilinear interaction models were calculated with depressive symptom severity and mindfulness at t2 as dependent variables. All data-analyses were performed on an intention-to-treat basis.

Results

Mediation analyses showed a significant, full mediation of the intervention effect on depressive symptom severity through mindfulness (indirect effect, a*b = 0.153, p < 0.01). Only the number of semesters (interaction: β = 0.24, p = 0.035) was found to moderate the intervention's effectiveness on depressive symptom severity at t2, and only baseline mindfulness (interaction: β = -0.20, p = 0.047) and baseline self-efficacy (interaction: β = -0.27, p = 0.012) were found to be significant moderators of the intervention effect on mindfulness at t2.

Conclusion

Our results suggest a mediating role of mindfulness. Moderation analyses demonstrated that the intervention improved depressive symptom severity and mindfulness independent of most examined baseline characteristics. Future confirmatory trials will need to support these findings.

Clinical Trial Registration

The trial was registered a priori at the WHO International Clinical Trials Registry Platform via the German Clinical Studies Trial Register (TRN: DRKS00014774; registration date: 18 May 2018).

Exposure to exposure: A protocol for leveraging exposure principles during training to address therapist-level barriers to exposure implementation

BACKGROUND

Exposure therapy is a highly effective but underutilized treatment for anxiety disorders. A primary contributor to its underutilization is therapist-level negative beliefs about its safety and tolerability for patients. Given functional similarities between anxious beliefs among patients and negative beliefs among therapists, the present protocol describes how exposure principles can be leveraged during training to target and reduce therapist negative beliefs.

METHODS

The study will take place in two phases. First, is a case-series analysis to fine-tune training procedures that is already complete, and the second is an ongoing randomized trial that tests the novel exposure to exposure (E2E) training condition against a passive didactic approach. A precision implementation framework will be applied to evaluate the mechanism(s) by which training influences aspects of therapist delivery following training.

ANTICIPATED RESULTS

It is hypothesized that the E2E training condition will produce greater reductions in therapists' negative beliefs about exposure during training relative to the didactic condition, and that greater reduction in negative beliefs will be associated with higher quality exposure delivery as measured by coding of videotaped delivery with actual patients.

CONCLUSION

Implementation challenges encountered to date are discussed along with recommendations for future training interventions. Considerations for expansion of the E2E training approach are also discussed within the context of parallel treatment and training processes that may be tested in future training trials.

Mechanisms of Action in Exposure Therapy

PURPOSE OF REVIEW

Exposure therapy is an effective treatment for anxiety-related disorders, but many individuals do not achieve full symptom relief, and return of fear is a common occurrence. Understanding how exposure therapy works enables further development of strategies to improve its effectiveness.

RECENT FINDINGS

Recent studies have examined mechanisms of exposure-based interventions across multiple levels of analysis, from cognitive and behavioral changes that occur during treatment to the neurobiological mechanisms underlying fear extinction. Belief change and reductions in safety behaviors and avoidance mediate symptom improvements during exposure therapy, suggesting plausible cognitive and behavioral mechanisms. On the neural level, increased activation of prefrontal regions during extinction learning is a likely mechanism of exposure. Improved understanding of the biological mechanisms of exposure have led to exciting developments in clinical research, including pharmacological augmentation, though clinical translation of basic research has produced mixed results. Though still in development, such translational research is a promising future direction for exposure-based interventions.

Imaginal Exposure for Disordered Eating Related Fears: An Initial Randomized Controlled Trial

Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Expositionsübungen und Verhaltensexperimente: Varianten des erfahrungsbasierten Lernens in der Verhaltenstherapie

Expositionsübungen (Reizkonfrontationen) stellen die wichtigste Interventionskomponente bei Angststörungen dar; Verhaltensexperimente die wichtigste beobachtungsbezogene Disputationsmethode. Beides sind Beispiele erfahrungsorientierten Lernens in der Verhaltenstherapie. In der vorliegenden Übersichtsarbeit werden diese Vorgehensweisen definiert, in ihren Durchführungsvarianten dargestellt und hinsichtlich ihrer logischen Begründung sowie ihrer hypothetischen Wirkmechanismen verglichen. Dabei wird deutlich, dass beide Ansätze gemäß dem Prinzip der Erwartungs- bzw. Befürchtungswiderlegung (expectancy violation) erwartungs- bzw. einstellungskonträre Erfahrungen ermöglichen sollen. Der Schwerpunkt bei den Expositionsübungen liegt auf der Veränderung des emotionalen Erlebens und automatisierter Vermeidungsreaktionen in bestimmten Zielsituationen, bei den Verhaltensexperimenten liegt er auf der Veränderung von Einstellungen und Erwartungen. Ferner wird bei den Expositionsübungen der Erwerb emotionaler Kompetenzen (Furchttoleranz) angestrebt, was bei Verhaltensexperimenten zumindest nicht primär intendiert ist. Zwar zielt die Fallkonzeption bei Expositionen mehr auf die Veränderung problematischer Handlungen/Vermeidungsreaktionen und bei Verhaltensexperimenten mehr auf die Veränderung problematischer Kognitionen, beide Interventionsvarianten konvergieren aber grundsätzlich hinsichtlich des übenden Ansatzes, bei dem durch häufige Wiederholung im Alltag positive Kontrasterfahrungen stabil im Gedächtnis verankert werden sollen.

Social engagement, self-efficacy, and posttraumatic stress symptoms across 6 months of psychotherapy

OBJECTIVE

The current study was conducted in a naturalistic treatment setting to examine whether and how perceptions about social engagement, trauma coping self-efficacy, and posttraumatic stress symptoms (PTS) influence one another across 6 months of psychotherapy for trauma survivors.

METHOD

The sample included 183 clients who reported exposure to traumatic events and significant PTS (PCL-5 ≥ 33). Participants (M_age  = 37.8, 53.6% female) completed surveys at intake, 3 months, and 6 months into treatment. A cross-lagged panel analysis was used to test the relationships among perceived social engagement, coping self-efficacy, and PTS across three assessment points.

RESULTS

PTS at 3-months was a mediator in the relationship between intake perceived social engagement and 6-month coping self-efficacy and between intake perceived social engagement and 6-month perceived social engagement.

CONCLUSIONS

PTS several months into treatment may serve as a mechanism between intake perceived social engagement and functional outcomes such as coping self-efficacy.