Madara Hall - Marinela

Mediators and mechanisms of change in cognitive-behavioral therapy

Johanna Böttcher, Jaap Lancee, Stefan Hofmann, Anna Kunze Speaker

Cognitive-behavioral therapy (CBT) leads to therapeutic change in a variety of psychological disorders. In the past decades, the majority of CBT research has focused on the efficacy of psychotherapy, which led us to conclude that CBT “works”. However, the mechanisms through which psychological treatments operate remain largely unknown and there is little empirical research to provide an evidence-based explanation of why treatment works and how therapeutic changes come about.

Understanding how or why psychotherapy leads to change is essential for clinical research and practice for a number of reasons (see also Kazdin, 2007, pp. 3-4): First, understanding the mechanisms of change can bring order and parsimony to the current wealth of interventions in use. Second, elaborating mechanisms of therapy will clarify the connections between treatment and its benefits on quite diverse outcomes including social, cognitive, emotional, behavioral, and physiological problems. Third, if we know how therapeutic changes come about, we can optimize such change by improving the therapeutic strategies that trigger the critical process(es). Fourth, understanding the process through which treatment operates can help identify variables that might be particularly influential in treatment outcome and allow for better selection of suitable patients. In sum, understanding how or why psychological interventions produce therapeutic change is necessary in order to eventually increase the effectiveness of psychological treatments. It therefore seems crucial to draw researchers’ and clinicians’ attention to the working mechanisms of CBT.

In this symposium, unique and exciting research as well as novel theoretical ideas on mechanisms of change in CBT-based psychological treatments will be presented. We will start with an overview on mediators of change in online CBT. Next, we will consider possible mechanisms of change in the treatment of insomnia. Moreover, we will look at mediators of the treatment effects of imagery rescripting versus imaginal exposure, two evidence-based treatments for a variety of emotional disorders. We conclude with a novel theoretical approach in clinical psychology called process-based therapy. The following presenters have agreed to take part the symposium:

1) Johanna Böttcher (FU Berlin, Germany) will present a systematic review on mediators of the treatment effects in internet-based CBT.

2) Jaap Lancee (University of Amsterdam, the Netherlands) will present data on a network analysis carried out in a study on the effects of insomnia treatment on depressive symptoms, focusing on the relationship between treatment, sleep symptoms, and depressive symptoms.

3) Anna Kunze (LMU Munich, Germany) will present data on a randomized controlled clinical trial that investigated the mechanisms of change in imagery rescripting versus imaginal exposure in a sample of nightmare sufferers.

4) Stefan Hofmann (Boston University, USA) will present his thoughts on process-based therapy, an innovative therapeutic approach in clinical psychology focusing on theory, mediators, and moderators of change.

Kazdin, A.E. (2007). Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology, 3, 1-27.

Mediators of change in Internet-based cognitive-behaviour therapy – a systematic review

Johanna Boettcher1, Anita Wilke, Pavle Zagorscak, & Thomas Berger

1Freie Universität Berlin, Berlin, Germany

Background: Numerous randomized controlled studies show that Internet-based interventions (IBI) are a low-threshold and easy-access treatment option for many mental disorders. But what makes these interventions work? The current review summarizes evidence on mediators of change in IBI.

Methods: We searched the literature for IBI studies that 1) reported potential mediators 2) within a RCT 3) for mental disorders in adults 4) with at least three measurement occasions.

Results: 28 studies met all inclusion criteria. Results on the therapeutic relationship were mixed, with only half of the trials reporting a significant association with treatment outcome. Most studies on cognitive factors found that change in cognitions (e.g. dysfunctional beliefs) mediated change in symptoms. The few studies on behavioral change factors showed that e.g. a reduction of safety behaviors mediated change in symptoms. A third group of studies investigated mindfulness and related concepts and consistently showed an association with treatment outcome.

Discussion: The current review paints a somewhat mixed picture. This is certainly due to the high variability in treatment formats and potential mediators. At the same time, the methodological quality of these studies is also diverse and only few studies make use of the excellent research conditions in Internet-based treatment formats.

Treating insomnia and depression: using network analysis to explore targeted treatment effects

Jaap Lancee1, Tessa F Blanken2 & Tanja Van der Zweerde3

1 Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands

2Department of Sleep and Cognition, Netherlands Institutefor Neuroscience, an Institute of the Royal Netherlands Academy of Arts andSciences, Amsterdam, The Netherlands.

3 Department of Clinical Psychology & EMGO Institute for Health and Care Research, VU University, Amsterdam, the Netherlands

Introduction. In a recent trial we found that Cognitive Behavioral Therapy for Insomnia (CBT-I) not only improved insomnia complaints, but also depressive symptoms. The question remains how CBT-I brings about the effects: via improvements in insomnia, or by affecting depression symptoms directly.

Methods. We performed a secondary data analysis on 104 patients (N=104) with insomnia (i.e. self-reported fulfilling of DSM-5 criteria) and (subclinical) depression. Participants were randomized to either guided web-based CBT-I or to a sleep diary. Insomnia and depression complaints were measured weekly for 10 weeks.

Results. Network analysis suggests that CBT-I predominantly affects insomnia symptoms, particularly difficulty maintaining sleep and early morning awakenings. While depressive symptoms also decline, this seems to occur via their relations to insomnia symptoms (specifically: sleep complaints) rather than via direct associations to treatment.

Conclusions. This study suggests that CBT-I firstly has its effects on insomnia symptoms and that the depressive symptoms follow the changes in insomnia symptoms. This is illustrated by the predominant conditional dependencies between treatment and insomnia symptoms. Through this network approach there is an opportunity to explore how treatments affect specific symptoms of psychological disorders, in existing (trial) datasets and future studies.

Keywords: insomnia, depression, CBT, online treatment, RCT, network analysis

Mediators of change in imagery rescripting and imaginal exposure for nightmares:

Evidence from a randomized wait-list controlled trial

Anna E. Kunze1, Jaap Lancee2, Nexhmedin Morina3, Merel Kindt2, and Arnoud Arntz2

1LMU Munich, Leopoldstraße 13, 80802 Munich, Germany

2University of Amsterdam, PO Box 15933, 1001 NK Amsterdam, Netherlands

3University of Münster, Fliednerstraße 21, 48149 Münster, Germany

Imagery rescripting (IR) and imaginal exposure (IE) are two efficacious treatments for nightmare disorder, but their discrete underlying mechanism(s) remain largely unknown. We therefore examined mediators of the treatment effect of IR and IE in a randomized wait-list controlled trial. Therapeutic outcomes were assessed at pre- and post-assessment, and mediator assessment took place in between treatment sessions in order to establish a temporal relationship between mediators and nightmare symptoms (i.e., frequency and distress). In line with the hypothesis, enhanced mastery (or self-efficacy) of the nightmare content mediated the therapeutic efficacy of IR. Furthermore, the treatment effects of IE were mediated by increased tolerability of the negative emotions elicited by nightmares. The results suggest that current theories about mediators of exposure treatments (i.e., increased emotion toleration) may generalize to IE for nightmares. Given that the working mechanisms of rescripting treatments to date remain largely unknown, the present data provide invaluable though preliminary evidence for the mediating role of mastery in rescripting-based therapies of aversive memories.

Process-based therapy: Psychological treatments focusing on theory, mediators and moderators of change

Stefan G. Hofmann, Boston University

Steven C. Hayes, University of Nevada, Reno

Cognitive Behavioral Therapy (CBT) has been an enormous empirical and practical success over its more than 50+ year history. However, the situation surrounding evidence-based care has dramatically changed, and it is important for CBT to change as well. For decades, evidence-based therapy has been defined in terms of scientifically validated protocols focused on syndromes. That era is now passing away. A new generation of evidence-based therapy has begun to move toward process-based interventions to target core mediators and moderators based on testable theories. This change could represent a paradigm shift in clinical science, leading to a decline of named therapies defined by set technologies, a decline of broad schools, a rise of testable models, a rise of mediation and moderation studies, the emergence of new forms of diagnosis based on functional analysis, a move from nomothetic to idiographic approaches, and a move toward processes that specify modifiable elements.