Intolerance of Uncertainty and Perfectionistic Beliefs About Parenting as Cognitive Mechanisms of Symptom Change During Cognitive Behavior Therapy for Perinatal Anxiety

ObjectiveA recent randomized controlled trial of group cognitive behavior therapy (CBGT) for perinatal anxiety showed that CBGT is effective in reducing anxiety and depression in pregnant and postpartum women. In secondary analyses, the role of potential mechanisms of symptom change was examined, including intolerance of uncertainty (IU), self-oriented parenting perfectionism (SOPP) and societal-prescribed parenting perfectionism (SPPP).MethodThe sample included 75 women (M_age = 31.99, SD = 3.57; 37.3% pregnant, 62.7% postpartum) who sought treatment for anxiety and completed the 6-week CBGT or 6-week waitlist within the larger trial. Measures of anxiety (State-Trait Inventory for Cognitive and Somatic Anxiety; STICSA), depression (Edinburgh Postnatal Depression Scale; EPDS), and the proposed mediators (IU, SOPP, SPPP) were completed at baseline and 6-weeks post-baseline.ResultsTwo moderated mediation models were evaluated to identify potential mediators of the effect of condition (CBGT, waitlist) on anxiety (STICSA; Model 1) or depressive symptoms (EPDS; Model 2). In Model 1, changes in IU partially mediated the effect of condition on anxiety (STICSA) for both pregnant and postpartum women. Changes in SOPP and SPPP were partial mediators for postpartum women only. Change in depression (EPDS) was also a partial mediator for pregnant women in this model. In Model 2, none of the cognitive variables mediated the effect of condition on depressive symptoms (EPDS). However, change in anxiety (STICSA) was a significant mediator of the effect of condition on depression (EPDS) and only among pregnant women.ConclusionsThe results provide support for IU, SOPP and SPPP as mechanisms of change during CBGT and identify differences in important mechanisms among pregnant and postpartum women.     

Homework

In commemoration of Dr. Aaron T. Beck’s enormous contributions to our field, I comment on the state of our knowledge regarding the role of homework in cognitive behavioral therapy. The available evidence suggests homework is a contributor to positive therapeutic outcomes in cognitive behavioral therapy. Although therapists play an important role in facilitating clients’ engagement with homework as they develop greater facility with CBT skills, little is known about the contributions of specific approaches to promoting homework engagement. I highlight some of these strategies and discuss the need for researchers to empirically evaluate them.     

Depression

Beck initially set out to test the Freudian notion that depression is a consequence of “anger turned inward” (rage directed the introjected parent for not gratifying infantile desires) but soon came to conclude that no such unconscious motivation existed and that instead depressed patients actually believe that they were unlovable or inadequate. He developed a treatment that he named cognitive therapy that is as efficacious as and more enduring than antidepressant medications. It stands as the most often tested and most widely practiced treatment for depression.     

Cognitive Reappraisal

A central tenet of Beck’s cognitive therapy (or cognitive behavior therapy) of the emotional disorders is that change in negative thought and beliefs is necessary for clinically significant symptom reduction in anxiety, depression, and other psychological conditions. Cognitive restructuring, a uniquely Beckian innovation, is a treatment strategy that directly targets cognitive reappraisal as the change mechanism responsible for symptom reduction. This commentary considers the origins of cognitive reappraisal in Beck’s cognitive therapy through the lens of cognitive restructuring and what treatment process research tells us about the mechanisms of change in cognitive restructuring.     

Adaptations for Youth

Aaron T. Beck exemplified the clinical scientist, willing to test his hypotheses, and willing to share his experiences and treatment features with others. Assessment and treatment of emotional disorders have been forever improved through the efforts of Aaron T. Beck. Using the psychological treatment of an emotional disorder in youth (i.e., anxiety), this commemorative reflects on how Aaron T. Beck’s clinical strategies have been impactful well beyond his initial focus. As a world-renowned clinical scientist, Beck’s work has influenced multiple fields addressing mental health. As a friend and colleague, Beck was a gentleman and a scholar.     

Introduction to the Beck Commemorative Special Feature

My father, Aaron Beck (“Tim” to those closest to him), would have been proud of this special issue of Cognitive and Behavioral Practice, and so honored. Anyone who knew my father, knew he was a scientist at heart. His curiosity, intelligence, and humility made him a great scientist and a productive researcher. This introduction shares a personal perspective and context for his contributions, including his lifelong commitment to enhancing the evidence for cognitive and behavioral practice.     

Emotional Schemas

Beck's cognitive model has stressed the influence of cognitive processing in eliciting and maintaining emotional disorders. The concept of schema is extended in Emotional Schema Therapy to account for beliefs, assumptions, and strategies that comprise problematic theories of emotion that result in unhelpful strategies of emotion regulation and acceptance of emotion. In the present paper the central concepts of Emotional Schema Therapy are elucidated and research supporting the model is reviewed.     

A Rumination-Focused Cognitive-Behavioral Therapy Self-Help Program to Reduce Depressive Rumination in High-Ruminating Japanese Female University Students: A Case Series Study

The present case series reports the preliminary test of a rumination-focused cognitive-behavioral therapy (RFCBT) self-help program to reduce depressive rumination among Japanese female undergraduates. A workbook-type self-help program based on RFCBT was implemented with 39 participants showing a high tendency toward rumination/worry. Data from 30 participants who completed one or more modules were analyzed quantitatively. The results showed significant reductions of rumination, worry, and anxiety at post-intervention. Further, semistructured interviews were conducted with 13 participants who completed the program, and verbatim data were examined using content analysis. The contents found to be useful and difficult differed for each participant and each module. Based on these results, the future implementation and dissemination of RFCBT is discussed.     

Telehealth for Dialectical Behavioral Therapy: A Commentary on the Experience of a Rapid Transition to Virtual Delivery of DBT

Telehealth has been rapidly adopted to provide continuity of delivery of mental health services in light of COVID-19. However, the remote implementation of intensive treatments like dialectical behavioral therapy (DBT) has been vastly understudied. The aim of the current commentary is to describe potential obstacles, propose solutions, and discuss advantages of transitioning from traditional in-person to a virtual delivery format for full model DBT. We speak to these points at multiple levels of relevance to clinical scientists and practitioners: (1) considerations about the virtual delivery format, (2) considerations for the virtual delivery of DBT specifically, and (3) person-level considerations (e.g., client, clinician). We illustrate the commentary using examples of obstacles encountered and solutions identified during our DBT team’s rapid transition to telehealth in response to COVID-19-related shut-downs and discuss considerations for the extension of telehealth delivery of DBT going forward. We are hopeful that the rapid transition to telehealth delivery of mental health services in response to COVID-19 serves as a call to action for clinicians to adapt and leverage technology to deliver DBT on a broader scale to improve patient health outcomes.