Exposure therapy for PTSD delivered to veterans via telehealth: predictors of treatment completion and outcome and comparison to treatment delivered in person

Recent research has focused on the effectiveness of evidence-based psychotherapy delivered via telehealth services. Unfortunately to date, the majority of studies employ very small samples and limited predictor and moderator variables. To address these concerns and further replicate and extend the literature on telehealth, the present study investigated the effectiveness of 12-session exposure therapy delivered either via telehealth (n = 62) or in person (n = 27) in veterans with posttraumatic stress disorder (PTSD). Findings demonstrated that although older veterans and Vietnam veterans were more likely to complete the telehealth treatment, telehealth findings were not influenced by patient age, sex, race, combat theater, or disability status. Exposure therapy delivered via telehealth was effective in reducing the symptoms of PTSD, anxiety, depression, stress, and general impairment with large effect sizes. Interestingly, exposure therapy via telehealth was less effective than exposure therapy delivered in person; however, lack of random assignment to condition limits conclusions of differential effectiveness. Overall, these findings support the utility of telehealth services to provide effective, evidence-based psychotherapies.     

Using telehealth to provide outpatient follow‐up to children with avoidant/restrictive food intake disorder

The COVID‐19 global health crisis compelled behavior analysts to consider alternatives to face‐to‐face services to treat children with feeding disorders. Research suggests telehealth is one method behavior analysts could use to initiate or continue assessment of and treatment for feeding disorders. In the current paper, we conducted pilot studies in which we analyzed chart records of patients with Avoidant/Restrictive Food Intake Disorder; who graduated from an intensive, day‐treatment program; and transitioned to an outpatient follow‐up program. In Experiment 1, we analyzed the data of participants who received follow‐up both in‐clinic and via telehealth. In Experiment 2, we analyzed goal attainment for participants who received outpatient follow‐up either in‐clinic exclusively or via telehealth exclusively. Results of both studies showed that outcomes were equivalent along most dimensions for in‐clinic and telehealth services. We provide recommendations for telehealth feeding services and discuss other considerations relevant to telehealth service delivery.     

Outcomes in clients transitioning from in-person counselling to telehealth counselling with trainees

The onset of the 2020 COVID-19 pandemic necessitated a rapid transition of mental health services from in-person to telehealth counselling. Despite the far-reaching impact of this transition, we know little about the impact of this transition on outcomes for clients working with counsellor trainees. The present study utilised longitudinal data collected from a counselling training centre at a major U.S. university to compare client ratings of depression, anxiety and working alliance across 1) in-person services delivered (i.e. pre-pandemic) and 2) telehealth services delivered after the pandemic began (i.e. intra-pandemic) among the same group of clients. Results support our hypothesis that changes in clients' self-reports would be generally equivalent across in-person and telehealth services. Depression and anxiety symptoms decreased, and working alliance tended to increase during both in-person and telehealth care; however, these trends were only statistically significant during telehealth services. Limitations related to sample size (N = 15 clients; up to 17 sessions per client) and low statistical power are discussed. Nonetheless, this study supports the growing body of literature supporting the efficacy of telehealth counselling services. We provide suggestions for future telehealth research and discuss implications for counsellor training.     

Psychological Distress in Australian Clients Seeking Family and Relationship Counselling and Mediation Services

There is little published data on the prevalence of psychological distress among individuals and couples seeking counselling and mediation services from non‐government organisations (NGOs). This national cross‐sectional study establishes the prevalence of psychological distress among clients seeking family and relationship counselling and mediation services from Relationships Australia. A national sample of 1,365 clients attending services in April to May 2012 completed the 10‐item Kessler Psychological Distress Scale (K10) after their first counselling or mediation session. Individual counselling (M = 23.01, SD = 8.97, 95% CI [22.05–23.97]) and couple counselling (M = 21.63, SD = 8.10, [20.86–22.41]) clients reported a mean K10 score comparable to those reported by clinical studies of clients with anxiety or affective disorders. One quarter to one fifth of these clients reported very high psychological distress. Clients accessing mediation services had a mean score of 18.13 (SD = 7.76; [17.51–18.75]), and one tenth of clients reported very high distress. These elevated rates of very high psychological distress suggest that mental health issues may be a significant problem for a large proportion of clients accessing counselling and mediation NGO services provided under Family Support Programs (FSP) funding. Implications for screening for mental health and appropriate treatment planning are discussed.     

Evaluating discrete trial teaching with instructive feedback delivered in a dyad arrangement via telehealth

Telehealth research in the field of applied behavior analysis (ABA) has focused on the training and supervision of others to implement various behavior analytic procedures. Current guidelines for practicing telehealth suggest that direct telehealth services may be appropriate for some individuals diagnosed with autism spectrum disorder, but more research is needed. This study evaluated the effects of discrete trial teaching with instructive feedback in a dyad arrangement delivered directly via telehealth to teach tact relations to 6 children diagnosed with autism spectrum disorder. All participants and the experimenter were located in different physical locations. All participants learned their primary and secondary targets, and 5 of the participants acquired the observational primary and secondary targets without direct teaching. Areas of future research and clinical implications are discussed in the context of telehealth service delivery.     

Making Lemonade out of Lemons: Dialectical Behavior Therapy via Telehealth During a Pandemic

The COVID-19 pandemic has created a burden on healthcare systems and increased demand for mental healthcare at a time when in-person services are limited. Many programs offering dialectical behavior therapy (DBT) for complex clients have pivoted to telehealth in order to increase access to critical mental healthcare. There is, however, limited research on the provision of telehealth treatment for clients with complex psychopathology more broadly, or the telehealth implementation of DBT more specifically. The aim of this study was to examine the use of telehealth services and related clinician attitudes and experiences in the context of DBT. We examined the degree of telehealth platform adoption among DBT clinicians, as well as changes in stress and self-care strategies. A supplemental aim was to gather clinicians’ recommendations for providing DBT via telehealth. Participants included N = 99 DBT practitioners (79.8% female; 20.2% male). Qualitative and quantitative methods were used for data analysis. Findings show that telehealth DBT has been widely adopted among DBT clinicians, and that clinicians’ attitudes to telehealth DBT are cautiously optimistic. Participants described three main areas of stress associated with DBT via telehealth provision, as well as lost and novel self-care strategies.     

Assessing the social validity of telehealth-based applied behavior analysis services for autism spectrum disorder

During the COVID-19 pandemic, applied behavior analysis services for many autistic individuals were transitioned to telehealth. The current study assessed caregiver-reported quality of life (QoL) and social validity for families of autistic children receiving only telehealth services (n = 96) or a combination of telehealth and in-person services (n = 173). Barriers to the telehealth experience were analyzed via an ANOVA, and the impact of funding source was analyzed using an independent samples t-test. Caregivers reported benefit across QoL and social validity items, with scores ranging from 3.31 to 4.44 (1 = least benefit, 5 = most benefit). While many caregivers reported no barriers regarding technology (44.61%), childcare (69.52%), and employment (64.68%), the presence of those barriers significantly impacted QoL and social validity scores. Funding source was not found to have a significant impact. Overall, caregivers found value in their child's telehealth services. Clinicians have an obligation to mitigate barriers to ensure the success of the intervention.     

Therapist Experiences and Attitudes About Implementing Internet-Delivered Parent-Child Interaction Therapy During COVID-19

It has been widely recognized that access to mental health treatment is imperative to address current and long-term stressors for children and parents during COVID-19. Internet-delivered Parent-Child Interaction Therapy (iPCIT, previously referred to as I-PCIT) is a strong model for remote service delivery during social distancing restrictions due to its empirical base. However, this treatment modality was not widely implemented before COVID-19, likely due to barriers to providing telehealth services. This mixed methods study conducted a follow-up survey to gather therapist experiences (N = 223) in delivering iPCIT during COVID-19, including qualitative data on the benefits and challenges to delivering iPCIT. The vast majority of therapists (82%) indicated that they transitioned to deliver PCIT via telehealth in response to COVID-19. PCIT caseloads decreased slightly from the first survey to the COVID-19 follow-up survey, but the racial and ethnic composition of caseloads were not significantly different between the two surveys. Of the 183 therapists who transitioned to deliver PCIT via telehealth, 82% expressed interest in continuing to provide iPCIT following the COVID-19 pandemic. Reported benefits of iPCIT included decreased barriers to access and the ability to practice skills within the naturalistic home environment. Challenges to iPCIT were primarily issues with technology as well as other logistical barriers, which could limit engagement for some families. Findings from this study may be beneficial in improving future implementation of iPCIT during and post-COVID-19.     

Person‐centred counsellors' experiences of working with clients in crisis: A qualitative interview study

Aims: This study aims to explore and understand person‐centred therapists’ experiences and work with clients at the pivotal point of crisis. Specifically: how do person‐centred therapists experience working with clients in crisis? Do they identify differences in crisis intervention compared to non‐crisis work? What do they perceive as helpful to crisis clients? How relevant are therapists' own experiences of crisis? Method: Participants were all experienced person‐centred therapists. Qualitative, semi‐structured interviews were conducted and the data were analysed qualitatively using person‐centred/phenomenological methodology. Results: Respondents identified differences in their experiences. Typically, therapists described polarity in their experience of danger and opportunity, also heightened energy levels within themselves, perceived higher levels of engagement, faster pace of work, experiences of reaching ‘relational depth’ earlier, and the importance of assisting symbolisation of clients' experience in awareness. Clients were experienced as vulnerable, unable to access previous coping mechanisms, in a state of breakdown and disintegration, but also as wide open, having dropped their usual defences, and more available to engage in therapy and enter the process of change and potential post‐crisis growth. Discussion: The findings are discussed in relation to prevailing models of crisis intervention, person‐centred theory and theoretical developments in post‐traumatic growth in the aftermath of crisis.     

Couple and family therapists’ experiences with Telehealth during the COVID-19 pandemic: a phenomenological analysis

In designing this study, we aimed to obtain a rich, phenomenological understanding of the experiences of couple and family therapists who transitioned their practice to telehealth due to the COVID-19 pandemic. Twelve experienced therapists from the U.S., Spain and Australia were interviewed in depth about their experiences of this transition, particularly how they developed and maintained therapeutic alliances in a virtual context with couples and families suffering pandemic-related hardships. The qualitative analysis identified 40 themes reflecting participants’ initial impressions of telehealth and their positive and negative reactions and adjustments to practicing remotely. Upon overcoming some initial wariness about providing services virtually, many participants described advantages to this way of working with families. Indeed, participants were creative in adjusting to this novel therapy modality, finding new ways to connect emotionally with their clients, to work meaningfully with children, to assess in-session dynamics, and to ensure their clients’ privacy and safety. Notably, several participants commented on the relatively slower development of alliances with new cases and the challenge of repairing split alliances between family members. Many of these difficulties were described as due to having minimal access to their clients’ raw emotions and the inability to use typical systemic interventions, such as moving family members around physically. Participants also reflected on being a “participant observer” to the upheaval caused by the pandemic, a distressing experience they shared with the families in their care.

     

Self‐Monitoring and the Metatraits

Prior attempts at locating self‐monitoring within general taxonomies of personality traits have largely proved unsuccessful. However, past research has typically neglected (a) the bidimensionality of the Self‐Monitoring Scale and (b) the hierarchical nature of personality. The objective of this study was to test hypotheses that the two self‐monitoring factors are located at the level of the metatraits. Using data from two large multi‐informant samples, one community (Sample 1: N = 552, M_age = 51.26, 61% female; N_Peers = 1,551, M_age = 48.61, 37% female) and one online (Sample 2: N = 3,726, M_age = 24.89, 59% female; N_Peers = 17,868, M_age = 26.23, 64% female), confirmatory factor analysis was used to test the hypotheses. Results confirmed hypotheses that acquisitive self‐monitoring would have a strong positive relation to metatrait Plasticity, whereas protective self‐monitoring would have a moderate negative relation to metatrait Stability. In both samples, constraining the correlation between acquisitive self‐monitoring and Plasticity to unity did not alter model fit indices, indicating that the two putatively distinct constructs are identical. Findings have wide‐ranging implications, including integration of the construct of self‐monitoring into the mainstream of personality research, as the latter moves toward the development of broad explanatory theories.     

Emotion regulation and psychopathological symptoms of Chinese school‐age children: A person‐centred and multi‐informant approach

Emotion regulation (ER) is a critical component of children's development. Many previous studies have utilised a single‐assessment method to reflect child ER, which might result in losing important information regarding the unique contribution of each informant. With a person‐centred approach and multi‐informant reports (mother, teacher and child), the current study examined 196 children's (age M = 9.21, SD = 1.10, range = 7–11 years; 51% girls) ER patterns and their associations with psychopathological symptoms in a Chinese sample. A model‐based clustering procedure resulted in 3 ER groups: the poor family ER group (n = 36), poor school ER group (n = 120), and overall good ER group (n = 40). Significant differences were found among ER clusters on teacher‐reported child psychopathological symptoms compared on the levels of withdrawn depression, somatic complain, thought problems and attention problems. No significant differences were found on the mother‐reported psychopathological symptoms. Compared with children in the poor school or poor family ER clusters, children in the overall good ER group demonstrated fewer psychopathological symptoms at school. Our results confirmed the advantage of adopting multi‐informant assessments to fully capture children's emotional profiles and linked these profiles with children's emotional and behavioural functioning at school.     

A LONGITUDINAL,PERSON‐CENTERED ANALYSIS OF EARLY HEAD START MOTHERS’ PARENTING

This study used a person‐centered approach to examine stability and change in parenting typologies across early childhood. Profiles were associated within and across time with contextual covariates, including demographic characteristics, risk factors, and Early Head Start participation. Participants were drawn from the Early Head Start Research and Evaluation Project (N = 2, 876). Parenting profiles were identified based on observed parenting dimensions at 14, 24, and 36 months, and pre‐Kindergarten (pre‐K). Results suggested a four‐profile solution at each time point: Supportive, Lukewarm (14 & 24 months)/Sufficient (36 months and pre‐K), Harsh, and Detached. Supportive was the largest, most stable, and most likely transitioned into profile while Harsh and Detached represented rare profiles with moderate to low membership stability across time. Depression and family conflict emerged as important correlates of unsupportive parenting profiles both within and across time. Findings are discussed in terms of their relevance for both policy and implementation practices for low‐income mothers with young children.     

Counselling in the workplace: How time‐limited counselling can effect change in well‐being

Background: Many employers provide counselling support on work and personal issues for their employees, but in times of economic pressure such services can be at risk if their effectiveness is not demonstrated. Aim: To evaluate whether time‐limited counselling in a workplace can effect sustained change in well‐being. Method: The study was carried out by a staff counselling team in a university setting. The Warwick‐Edinburgh Mental Well‐being Scale (WEMWBS) was completed by clients at the beginning and end of counselling, and at three and six months following. A non‐treatment comparison group completed the survey at the same intervals. Results: The results of our investigation show clearly that the effect of time‐limited counselling (average seven sessions) on distressed clients is positive. The evidence of our treatment group suggests that they acquire an increased sense of well‐being as a result of the experience of counselling with a significant statistical difference between pre‐and post‐counselling treatment group scores on the WEMWBS and consistently higher scores found post counselling. The improvement was maintained at the same level for at least six months following the end of counselling. Conclusions: The provision of time‐limited counselling by employers is an effective support for personal difficulties affecting work.     

Benchmarking Treatment Effectiveness of Community‐Delivered Trauma‐Focused Cognitive Behavioral Therapy

It is critical for urban youth with post‐traumatic stress disorder (PTSD) living in poverty to have access to evidence‐based interventions for their traumatic stress. However, there is limited research on the effectiveness of these interventions when provided in urban, community settings. The objectives of the current study are to (a) evaluate the effectiveness of trauma‐focused cognitive behavioral therapy delivered from 2013 to 2016 in 15 behavioral health agencies on youth (N = 114) PTSD as well as  general mental health symptoms and  functioning, and (b) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health System, a system that has invested significantly in the training and ongoing support of clinicians providing high‐quality trauma services to youth since 2012. From baseline to last assessment, youth PTSD symptom severity (d = 0.34), PTSD functional impairment (d = 0.38), and overall mental health problem severity (d = 0.29) improved. The effect sizes of  improvements were smaller than effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF‐CBT and provides preliminary findings with regard to the effectiveness, and transportability, of TF‐CBT to urban community settings that serve youth in poverty.     

Self‐Enhancement on a Self‐Categorization Leash: Evidence for a Dual‐Process Model of First‐ and Third‐Person Perceptions

Research suggests that first‐ and third‐person perceptions are driven by the motive to self‐enhance and cognitive processes involving the perception of social norms. This article proposes and tests a dual‐process model that predicts an interaction between cognition and motivation. Consistent with the model, Experiment 1 (N = 112) showed that self‐enhancement drove influence judgments when messages were normatively neutral—people reported first‐person perceptions for in‐group‐favoring messages and third‐person perceptions for out‐group‐favoring messages. Experiment 2 (N = 208) showed an additive effect when social norms were also in‐group‐enhancing, but showed a decreased effect when social norms and group‐enhancement were discordant. The findings are hard to reconcile with pure motivational or cognitive explanations, but are consistent with the proposed dual‐process model.     

A Self‐Categorization Explanation for the Third‐Person Effect

Three studies tested a self‐categorization theory explanation for the third‐person effect. In Study 1 (N= 49) undergraduate students judged the influence of the National Enquirer, Wall Street Journal, and TV show Friends on themselves, relative to low‐ and high‐status outgroup members, and other undergraduate students. The profile of first‐ and third‐person perceptions was largely consistent with predictions, and the size of the third‐person effect decreased as perceived similarity to target others increased—but only for media that were normative for comparison others. Study 2 (N= 49) provided evidence for this process with different media and showed that the profile of first‐ and third‐person perceptions matched closely with perceived norms of media consumption—but not the social desirability of those media. Study 3 (N= 64) showed that the third‐person effect for the same media and target other shifts with the frame of reference in which the judgment is made. Taken together, the findings are consistent with self‐categorization theory and difficult to reconcile with other explanations.     

Strengthening and Expanding Child Services in Low Resource Communities: The Role of Task‐Shifting and Just‐in‐Time Training

In the United States, the demand for child mental health services is increasing, while the supply is limited by workforce shortages. These shortages are unlikely to be corrected without significant structural changes in how mental health services are provided. One strategy for bridging this gap is task‐shifting, defined as a process by which services that are typically delivered by professionals are moved to individuals with less extensive qualifications or training. Although task‐shifting can increase the size of the workforce, there are challenges related to training new workers. In this paper, we propose Just‐In‐Time Training (JITT) as one strategy for improving task‐shifting efforts. We define JITT as on‐demand training experiences that only include what is necessary, when it is necessary, to promote competent service delivery. We offer a proof of concept from our own work shifting counseling and academic support tasks from school mental health professionals to pre‐baccalaureate mentors, citing lessons learned during our iterative process of JITT development. We conclude with a series of key considerations for scaling up the pairing of task‐shifting and JITT, including expanding the science of JITT and anticipating how task‐shifting and JITT would work within the context of dynamic mental health service systems.     

The Efficacy of Interventions Aimed at Reducing Procrastination: A Meta‐Analysis of Randomized Controlled Trials

This meta‐analysis investigated the efficacy of interventions aimed at reducing procrastination in randomized controlled trials. Twelve studies, with a total of 646 participants, met inclusion criteria. The significant meta‐analytic effect size, Hedges's g = 1.18, indicates that the interventions had a large positive effect. Three variables significantly moderated effect size: Higher effects were associated with interventions delivered in person, student samples, and a no‐treatment control condition. The results lay a foundation for procrastination treatment and future research.     

Therapeutic outcomes in the Welsh Government's school‐based counselling strategy: An evaluation

Aims: The purpose of this study was to evaluate the outcomes of school‐based counselling, as delivered in the Welsh Government's School‐based Counselling Strategy, for reducing psychological distress in young people aged 11–18. Method: The study used a quantitative cohort design, comparing levels of distress on either the Young Person's CORE (YP‐CORE) or the Strengths and Difficulties Questionnaire (SDQ) from baseline to endpoint. Data were available on 3613 episodes of counselling, across 42 datasets. Meta‐analytical procedures were used to identify the mean effect size and predictors of outcomes. Results: Within each dataset, counselling was associated with significant reductions in psychological distress, with a mean effect size (d) of 0.93(95% CI = 0.89–0.97) using a fixed effects model and 1.09 (95% CI = 0.97–1.22) using a random effects model. Datasets using the YP‐CORE had larger effect sizes than those using the SDQ, and datasets with more complete response rates had lower outcomes than those with poorer response rates. Conclusion: The results confirm that school‐based counselling, as delivered in the UK, is associated with significant reductions in psychological distress, comparable to adult counselling and psychotherapy services.