Translating CBM-I Into Real-World Settings: Augmenting a CBT-Based Psychiatric Hospital Program

Cognitive bias modification for interpretation (CBM-I) is an appealing augmentation to cognitive-behavioral therapy (CBT) because it targets cognitive bias efficiently via computerized training. Few studies have tested the combination of CBM-I and CBT, and none have translated lab-based CBM-I protocols to an acute psychiatric setting. The present study describes the development and implementation of CBM-I as an augmentation to a CBT-based partial hospital. We developed a transdiagnostic CBM-I based on the word–sentence association paradigm (WSAP), which reinforces individuals for endorsing benign interpretations and rejecting negative interpretations of ambiguous sentences. Over two iterations of development, we randomly assigned patients (N = 127; M age = 34.21; 58% female, 40% male, 2% nonbinary) to either CBM-I or a control group (Phase 1: neutral WSAP task; Phase 2: treatment as usual). CBM-I comprised daily sessions (10 minutes) completed during program hours, and number of sessions varied naturalistically according to patient length of stay. Primary outcomes included feasibility, acceptability, and target engagement (interpretation bias). CBM-I was feasible and acceptable to acute psychiatric patients, and successfully shifted interpretation for novel stimuli. Patient feedback suggested that participants viewed CBM-I as bolstering their primary CBT-based care. Exploratory analyses examining clinical benefit revealed a small between-group effect on anxiety severity (d = 0.378), but no group differences on depression outcomes (d = 0.008). Findings indicate that CBM-I is a feasible and acceptable augmentation to CBT-based partial hospital care. Future studies are warranted to determine who is most likely to benefit from this low-intensity approach.     

A Single-Session Online Cognitive Bias Modification of Interpretations Modified for Adults With Anxiety and Depressive Symptoms

Anxiety and depression are common, co-occurring, and costly mental health disorders. Cognitive bias modification aims to modify biases to reduce associated symptoms. Few studies have targeted multiple biases associated with both anxiety and depression, and those that have lacked a control condition. This study piloted a single-session online cognitive bias modification (known as CBM-IA) designed to target two biases associated with anxiety and depression—interpretation bias and attribution style—in adults with varying levels of anxiety and depressive symptoms. Participants (18–26 years) with at least mild levels of anxiety/stress and depressive symptoms on the DASS-21 were randomly allocated to an intervention (n = 23) or a control (n = 22) condition. The training consisted of a single-session online CBM-IA to encourage positive interpretations and a positive attribution style.Interpretation bias, attribution style, anxious and depressive mood states, and anxiety, stress and depressive symptoms improved at posttraining and at follow-up, irrespective of condition. Changes in interpretation bias from pre- to posttraining were significantly associated with changes in anxious mood state. CBM-IA, as implemented in this single-session pilot study, did not significantly reduce targeted biases and symptoms compared to a control condition. This adds to the mixed evidence on the efficacy of single-session CBM-I for altering biases and symptoms.     

HabitWorks: Development of a CBM-I Smartphone App to Augment and Extend Acute Treatment

The month following discharge from acute psychiatric care is associated with increased risk of relapse, rehospitalization, and suicide. Effective and accessible interventions tailored to this critical transition are urgently needed. Cognitive bias modification for interpretation (CBM-I) is a low-intensity intervention that targets interpretation bias, a transdiagnostic process implicated in the development and maintenance of emotional disorders. We describe the development of a CBM-I smartphone app called HabitWorks as an augmentation to acute care that extends through the high-risk month postdischarge. We first obtained input from various stakeholders, including adults who had completed partial hospital treatment (patient advisory board), providers, CBM experts, and clinic program directors. We then iteratively tested versions of the app, incorporating feedback over three waves of users. Participants were recruited from a partial hospital program and completed CBM-I sessions via the HabitWorks app while attending the hospital program and during the month postdischarge. In this Stage 1A treatment development work, we obtained preliminary data regarding feasibility and acceptability, adherence during acute care, and target engagement. Pilot data met our a priori benchmarks. While adherence during acute treatment was good, it decreased during the postacute period. Qualitative feedback was generally positive and revealed themes of usability and helpfulness of app features. Participants varied in their perception of skill generalization to real-life situations. The feasibility and acceptability data suggest that a controlled trial of HabitWorks is warranted.     

A Randomized Test of Interpretation Bias Modification for Perfectionism Versus Guided Visualization Relaxation Among High Perfectionistic Undergraduate Students

Clinical perfectionism contributes to the onset and maintenance of multiple psychological concerns. We conducted a randomized, longitudinal test of the efficacy of a web-based intervention for perfectionism (specifically, cognitive bias modification, interpretation retraining; CBM-I), compared to an active treatment comparison condition (specifically, guided visualization relaxation training) for reducing perfectionism and related psychopathology. College students (N = 167) with elevated perfectionism were randomized to one of the two study conditions and were asked to complete their assigned intervention twice weekly for 4 weeks. Participants completed measures of perfectionism and psychological symptoms at baseline, 2 weeks (midway through the intervention period), 4 weeks (at the conclusion of the intervention period), and 8 weeks (1 month follow-up). CBM-I was rated as acceptable overall, though relaxation training was rated slightly more favorably. CBM-I outperformed relaxation training on improving perfectionism-relevant interpretation biases (i.e., increasing nonperfectionistic interpretations and decreasing perfectionistic interpretations), though with small effect sizes and inconsistency across study timepoints. Self-reported perfectionism showed small decreases across time in both intervention conditions. Support was found for a key hypothesized mechanism of CBM-I, such that randomization to CBM-I had a longitudinal, indirect effect on decreasing psychopathology symptom scores through improving perfectionism-relevant interpretation biases. However, in light of small effect sizes, the present study failed to provide compelling evidence that CBM-I for perfectionism contributes meaningfully to the treatment of perfectionism.     

Interpretation Bias Training in Depressed Adolescents: Near- and Far-Transfer Effects

Depressed adolescents are characterized by negative interpretation biases. Although investigators have used cognitive bias modification for interpretation (CBM-I) to experimentally manipulate interpretation biases in depressed adults, the near- and far-transfer effects are not well understood in adolescents diagnosed with Major Depressive Disorder (MDD). In this study, we extend previous research by investigating the near- and far-transfer effects of 6 sessions of Positive versus Neutral CBM-I on independent measures of interpretation bias (near-transfer effects) and on attention biases and clinical symptoms (far-transfer effects) in a sample of adolescents with MDD (n = 46). At post-training, adolescents who received Positive CBM-I interpreted ambiguous scenarios more positively than did participants who received Neutral CBM-I, providing evidence of training effectiveness. There was no evidence, however, of near- or far-transfer effects. These findings raise concerns about the malleability of interpretation biases in adolescent depression and suggest that further work is needed to establish the clinical utility of CBM-I for adolescents with MDD.     

Practice makes perfect: Training the interpretation of emotional ambiguity

The interpretation of emotionally ambiguous words, sentences, or scenarios can be altered through training procedures that are collectively called cognitive bias modification for interpretation (CBM-I). In three experiments, we systematically manipulated the nature of the training in order to discriminate between emotional priming and ambiguity resolution accounts of training effects. In Experiment 1 participants completed word fragments that were consistently related to either a negative or benign interpretation of an ambiguous sentence. In a subsequent semantic priming task they demonstrated an interpretation bias, in that they were faster to identify relatedness of targets that were associated with the training-congruent meaning of an emotionally ambiguous homograph. We then manipulated the training sentences to show that interpretation bias was eliminated when participants simply completed valenced word fragments following unrelated sentences (Experiment 2), or completed fragments that were related to emotional but unambiguous sentences (Experiment 3). Only when participants were required to actively resolve emotionally ambiguous sentences during training did changes in interpretation emerge at test. Findings suggest that CBM-I achieves its effects by altering a production rule that aids the selection of meaning from emotionally ambiguous alternatives, in line with an ambiguity resolution account.     

Cognitive bias modification as a strategy to reduce children's fears and concerns about the secondary school transition

Background and objectives: Cognitive Bias Modification of Interpretations (CBM-I) has emerged as an anxiety-reducing tool for children and adolescents, targeting maladaptive interpretations of everyday situations. This literature falls short of addressing whether the effects of CBM-I extend to worries about a real-life stressor, such as a school transition. Design: The study comprised a between-groups design comparing the effects of CBM-I to an active control (AC) intervention in children. Method: We recruited 38 children within two months of their primary–secondary school transition and investigated the capacity for multi-session, parent-administered CBM-I, compared to an AC condition, to modify cognitive style and reduce anxiety symptoms and school concerns. Results: While benign interpretations increased significantly and negative interpretations tended to decrease following CBM-I, both interventions significantly reduced anxiety symptoms and school concerns. Conclusions: These findings indicate that anxiety-reducing effects of CBM-I in children extend to a real life stressful event, but that equivalent anxiety reduction may be achieved through exposure to potentially worrying situations and parent–child interaction in the absence of bias modification.     

A Pilot Feasibility Open Trial of an Interpretation Bias Intervention for Parents of Anxious Children

Interpretation bias is a transdiagnostic mechanism underlying anxiety. Theoretical models highlight the role of parental interpretation bias in predicting and maintaining child anxiety. However, very few studies have examined parent interpretation bias as a treatment target. The current pilot study tested the feasibility and acceptability of an interpretation bias intervention delivered by a smartphone app, called HabitWorks, in parents of anxious children who self-reported at least mild symptoms of anxiety and negative interpretation bias.Parents of anxious youth (ages 8 to 16) were recruited from the waitlists of three child anxiety clinics. They were asked to complete interpretation modification exercises via the HabitWorks app 3 times per week for 1 month. Participants completed assessments at pre- and post-intervention and 1-month follow-up to assess changes in interpretation bias, anxiety symptoms, and overall perceptions of HabitWorks.Participants (N = 14) (M_age = 44.36; 14.29% men, 85.71% women) completed an average of 13.29 exercises out of the 12 prescribed. Acceptability ratings were high. Interpretation bias, as measured by an assessment version of the intervention exercise, significantly improved from pre- to posttreatment, and these improvements were maintained at the 1-month follow-up. Anxiety symptoms significantly improved from the “mild” severity range to the “none to minimal” range.In this pilot feasibility study in parents of anxious youth, HabitWorks was a feasible and acceptable low-intensity intervention. These preliminary results support a future controlled trial of HabitWorks for parents. Future studies are also needed to test whether targeting interpretation bias in parents has downstream effects on maladaptive parent behaviors and ultimately, child interpretation bias and anxiety.     

Modifying Threat-related Interpretive Bias in Adolescents

Socially anxious feelings sharply increase during adolescence and such feelings have been associated with interpretive biases. Studies in adults have shown that interpretive biases can be modified using Cognitive Bias Modification procedures (CBM-I) and subsequent effects on anxiety have been observed. The current study was designed to examine whether the CBM-I procedure has similar effects in adolescents. Unselected adolescents were randomly allocated to either a positive interpretation training (n = 88) or a placebo-control condition (n = 82). Results revealed that the training was successful in modifying interpretations and effects generalized to a new task. The interpretive bias effects were most pronounced in individuals with a threat-related interpretive bias at pre-test. No effects on state anxiety were observed. The current findings are promising with regard to applying bias modification procedures to adolescents, while further research is warranted regarding emotional effects.     

Enhancing the Efficacy of Cognitive Bias Modification for Social Anxiety

Cognitive bias modification for interpretation (CBM-I) is a promising treatment modality for social anxiety disorder, but effect sizes are relatively small across investigations (Hallion & Ruscio, 2011). Additionally, the extent to which CBM-I impacts other cognitive, emotional, and behavioral outcomes is unclear. This study investigated whether two empirically supported treatment components for anxiety disorders, imaginal exposure (IE) and relaxation, augment the effects of CBM-I and increase the extent to which the effects of CBM-I generalize to behavioral and affective outcomes. We randomly assigned 111 undergraduate students with social anxiety to undergo IE, relaxation, or neutral thinking prior to CBM-I, then measured their interpretation biases, as well as their speaking time, anxiety, and subjective evaluations of performance during a speech task. Results indicated that individuals who received IE prior to CBM-I evidenced more adaptive interpretation biases and less behavioral avoidance during the speech task than did individuals who engaged in relaxation or neutral thinking. However, they did not report differential anxiety, habituation, or evaluations of their performance on the speech task. These findings suggest that the combination of CBM-I with adjunct components that target behavioral, rather than cognitive, mechanisms can facilitate transfer of the effects of CBM-I to reducing behavioral avoidance.     

Acceptability,Feasibility, and Effectiveness of Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in New York

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive–compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen’s d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.     

Effects of contingencies of self‐worth and sensitivity to indebtedness on optimistic bias in seeking help for depression

The occurrence of the optimistic bias in seeking help for depressive symptoms has been attributed to the threat‐to‐self and equity theories. The current study tested the hierarchical relationships between contingencies of self‐worth (CSW), self‐esteem (SE), sensitivity to indebtedness (SI), and optimistic bias in seeking formal/informal help for depression. An online questionnaire survey was conducted with Japanese university students (n = 1000). Results from structural equation modeling analysis revealed the mediating effect of CSW on SE and optimistic bias. SI was positively related to optimistic bias in symptom recognition and informal help‐seeking. The results suggest that both CSW and SI are responsible for the occurrence of optimistic bias in seeking help for depression. Cognitive patterns in recognizing personal and others' depressive symptoms and needs for seeking help were discussed.     

“Do More,Feel Better”: Pilot RCT of Lay-Delivered Behavioral Activation for Depressed Senior Center Clients

This pilot randomized control trial (RCT) tested “Do More, Feel Better” (DMFB), a lay-delivered Behavioral Activation intervention for depressed senior center clients. The study examined: (1) the feasibility of training older lay volunteers to fidelity; and (2) the acceptability, safety, and impact of the intervention. Twenty-one lay volunteers at four senior centers were trained in DMFB. Fifty-six depressed clients were randomized to receive 9 sessions of DMFB or Behavioral Activation delivered by social workers (MSW BA). Research assessments of overall client activity level (BADS) and depression severity (HAM-D) were conducted at baseline and Weeks 3, 6, and 9. Eighty-one percent of lay volunteers who underwent training were formally certified in DMFB. Depressed clients receiving each intervention reported high levels of satisfaction and showed large and clinically significant changes in 9-week activity level (d ≥ 1.35) and depression severity (d ≥ 3.34). Differences between treatment groups were very small for both activity level (d_MSW = 0.16; 95% CI, -0.70 to 1.02) and depression (d_MSW = 0.14; 95% CI, -0.63 to 0.91). Increases in activity level were associated with decreases in depression (β = -0.42; 95% CI, -0.55 to -0.30). Both interventions appeared to work as intended by increasing activity level and reducing depression severity. “Do More, Feel Better” shows the potential of evidence-based behavioral interventions delivered by supervised lay volunteers, and can help address the insufficient workforce available to meet the mental health needs of community-dwelling older adults.     

Validation of an interpretation bias assessment for body dissatisfaction

Currently, research on interpretation bias and body dissatisfaction is limited. The few experimental paradigms that have been used to explore this phenomenon utilized a method that may not accurately capture the nature of interpretation bias as explained by cognitive theory. The present study investigated the reliability and validity of a novel computerized assessment of interpretation bias (WSAP) for body dissatisfaction, which may more accurately reflect the cognitive processing involved in such bias by implementing the Word Sentence Association Paradigm (WSAP), a previously established method of measuring interpretation bias in other clinical populations. Undergraduate females (n = 214) completed the WSAP and other measures. Results indicate initial support for the WSAP as a valid, reliable measure of interpretation bias for body dissatisfaction. Although preliminary, this study contributes to the minimal research in this area and serves as the first psychometric investigation of the WSAP to measure such interpretation bias for body dissatisfaction.     

Modifying Obsessive-Compulsive Beliefs about Controlling One’s Thoughts

Cognitive models of obsessive-compulsive disorder propose that beliefs about the importance of and need to control thoughts (ICT) are central to the maintenance of the disorder. Cognitive Bias Modification for Interpretation (CBM-I) can be used to experimentally test this theory and may also have clinical utility as an adjunct therapeutic tool. The current study extended previous research to investigate whether two CBM-I sessions (one within and one outside the laboratory) would augment effects on obsessive-compulsive beliefs and behavior. We randomly allocated undergraduate participants high in ICT beliefs to a Positive (n = 30) or Control (n = 36) CBM-I condition and conducted multi-modal assessments immediately following the first training and at one-week follow-up. As predicted, participants in the Positive condition reported a reduction in obsessive-compulsive beliefs from baseline to follow-up (partial η ² = .42), whereas those in the Control condition did not. Participants responded more adaptively to the ICT relevant stressor task at follow-up compared to post-intervention, but there was no significant difference between conditions. Likewise, participants reported a reduction in obsessive symptoms over time that did not differ between conditions. The findings are considered in light of cognitive models of OCD, and clinical implications are discussed.     

Developing a measure of interpretation bias for depressed mood: An ambiguous scenarios test

The tendency to interpret ambiguous everyday situations in a relatively negative manner (negative interpretation bias) is central to cognitive models of depression. Limited tools are available to measure this bias, either experimentally or in the clinic. This study aimed to develop a pragmatic interpretation bias measure using an ambiguous scenarios test relevant to depressed mood (the AST-D).¹ In Study 1, after a pilot phase (N = 53), the AST-D was presented via a web-based survey (N = 208). Participants imagined and rated each AST-D ambiguous scenario. As predicted, higher dysphoric mood was associated with lower pleasantness ratings (more negative bias), independent of mental imagery measures. In Study 2, self-report ratings were compared with objective ratings of participants’ imagined outcomes of the ambiguous scenarios (N = 41). Data were collected in the experimental context of a functional Magnetic Resonance Imaging scanner. Consistent with subjective bias scores, independent judges rated more sentences as negatively valenced for the high versus low dysphoric group. Overall, results suggest the potential utility of the AST-D in assessing interpretation bias associated with depressed mood.     

Presidential Address: Are the Obsessive-Compulsive Related Disorders Related to Obsessive-Compulsive Disorder? A Critical Look at DSM-5’s New Category

The 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) includes a new class of obsessive-compulsive and related disorders (OCRDs) that includes obsessive-compulsive disorder (OCD) and a handful of other putatively related conditions. Although this new category promises to raise awareness of underrecognized and understudied problems, the empirical validity and practical utility of this new DSM category is questionable. This article critically examines the arguments underlying the new OCRD class, illuminates a number of problems with this class, and then discusses implications for clinicians and researchers.     

Cognitive bias modification of interpretations: A viable treatment for child and adolescent anxiety?

Anxiety disorders in children and adolescents are common and impairing. As many patients do not benefit from – or have difficulties accessing – frontline treatments, novel, effective and easy-to-deliver interventions are needed. Cognitive Bias Modification of Interpretations (CBM-I) training has been used to treat adult anxiety disorders. CBM-I methods train individuals to endorse benign rather than negative resolutions of ambiguous cues. Developmental extensions of CBM-I are important for several reasons. First, implementing CBM-I in symptomatic children and adolescents may facilitate early preventative gains. Second, as training uses simple learning mechanisms, CBM-I may reflect a developmentally-suitable strategy for shaping adaptive processing styles. Third, as this age range involves protracted neurocognitive maturation and associated plasticity, administering CBM-I early could drive powerful, long-lasting benefits for emotional development. Finally, data from CBM-I studies could inform the cognitive mechanisms involved in the genesis of early-emerging anxiety. This paper provides the first organised review of CBM-I studies conducted in children and adolescents, and contains suggestions for future research that may help realise the therapeutic potential of early CBM-I interventions.     

Positive Interpretation Bias Predicts Longitudinal Decreases in Social Anxiety

Theoretical models of social anxiety suggest that distorted interpretation processes contribute to its development and maintenance, although the pathways through which this occurs are not well understood. Therefore, the present longitudinal study sought to determine whether negative interpretation bias, positive interpretation bias, and interpretation inflexibility (the degree to which participants correctly revise initial interpretations) predict changes in social anxiety over time. In an important advance over prior studies, individual differences in working memory capacity (WMC) were accounted for, as WMC is thought to play a crucial role in the generation and maintenance of interpretation biases. Following a baseline assessment of social anxiety, interpretation biases, and WMC, participants completed follow-up assessments of social anxiety both 2 weeks (n = 106) and 4 weeks (n = 96) later. After controlling for baseline social anxiety and WMC, greater positive interpretation bias was found to predict lower social anxiety at both follow-ups. Neither negative interpretation bias nor interpretation inflexibility was significantly associated with follow-up social anxiety. These results provide support for greater positive interpretation bias as a facilitator of decreases in social anxiety and a potential target for clinical intervention.     

Perceptions of Cognitive-Behavioral Therapy and Antidepressant Medication for Depression After Brief Psychoeducation: Examining Shifts in Attitudes

The majority of people with depression in the United States either never seek treatment or gravitate exclusively to antidepressant medication (ADM), despite the existence of other effective treatments, such as cognitive-behavioral therapy (CBT). Reluctance to use psychotherapy is partly due to lack of appropriate mental health literacy and perceptions of low treatment acceptability (appropriateness for a given problem) and credibility (treatment logicalness, and whether the patient expects improvement). In the current investigation, we examined whether providing psychoeducation about CBT for depression would change participant perceptions of the treatment’s acceptability and credibility. We recruited 554 (female n = 314; 57%) participants across two online studies, and assessed their baseline perceptions of CBT and ADM using modified Treatment Acceptability (TAAS) and Treatment Credibility and Expectancy (CEQ) scales. Participants were subsequently presented with evidence-based, expert-vetted psychoeducational materials describing CBT and ADM, and were asked to recomplete the TAAS and CEQ. In Study 1, participants endorsed significantly higher CBT-CEQ (credibility/expectancy) scores postpsychoeducation. In Study 2, participants endorsed significantly lower CBT-TAAS (acceptability), and among those with no exposure to depression treatments, endorsed significantly higher CBT-CEQ scores postpsychoeducation. In both studies, there were no perceptual changes of ADM after the psychoeducation. Finally, in Study 2, endorsement of a biological model of depression and depressive symptoms were negatively predictive of CBT’s acceptability and credibility and expectancy postpsychoeducation. Perceptions of credibility and expectancy of CBT for depression appear malleable even after exposure to brief psychoeducation, whereas shifting perceptions of CBT’s acceptability may require more extensive intervention.